Basic Information
| Provider Information | |||||||||
| NPI: | 1922308386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | CASAC-T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 574 ST NICHOLAS AVE | ||||||||
| Address2: | 12 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2129669537 | ||||||||
| FaxNumber: | 2125845450 | ||||||||
| Practice Location | |||||||||
| Address1: | 598 BROADWAY | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2129669537 | ||||||||
| FaxNumber: | 2125845450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2010 | ||||||||
| LastUpdateDate: | 11/01/2010 | ||||||||
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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 | 101YA0400X | 02249145 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 02249145 | 01 | NY | OASAS | OTHER |