Basic Information
Provider Information | |||||||||
NPI: | 1679972111 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TARVER | ||||||||
FirstName: | MITCHELL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TARVER | ||||||||
OtherFirstName: | MITCHELL | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 205 COUNTY ROAD 134 | ||||||||
Address2: |   | ||||||||
City: | BREMEN | ||||||||
State: | AL | ||||||||
PostalCode: | 350333061 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2058766028 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 205 COUNTY ROAD 134 | ||||||||
Address2: |   | ||||||||
City: | BREMEN | ||||||||
State: | AL | ||||||||
PostalCode: | 350333061 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2058766028 | ||||||||
FaxNumber: | 2056680894 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/21/2014 | ||||||||
LastUpdateDate: | 02/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 3601C | AL | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.