Basic Information
| Provider Information | |||||||||
| NPI: | 1154372563 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DURHAM | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 311-4E JUDGES ROAD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284053655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107916767 | ||||||||
| FaxNumber: | 9107916890 | ||||||||
| Practice Location | |||||||||
| Address1: | 311-4E JUDGES ROAD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284053655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107916767 | ||||||||
| FaxNumber: | 9107916890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 08/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 4175 | NC | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | N | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 6001347 | 05 | NC | MEDICAID |