Basic Information
| Provider Information | |||||||||
| NPI: | 1871949016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | CORMICK | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.A.ED. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 KALISTE SALOOM RD | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705084230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372347109 | ||||||||
| FaxNumber: | 3372347898 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 KALISTE SALOOM RD | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372347109 | ||||||||
| FaxNumber: | 3372347898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2016 | ||||||||
| LastUpdateDate: | 05/30/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | LA | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1467745000 | 01 | LA | NPI | OTHER |