MEDICARE: RAKIBA L MITCHELL LPC, NCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YS0200X	School Counselor	IF0000000196562	MI
2	101YP2500X	Professional Counselor	6401011321	MI

General Provider Information

NPI Number	:	1487381158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAKIBA L MITCHELL LPC, NCC

Provider Business Mailing Address
First Line	:	SOUTHEASTERN HIGH SCHOOL
Second Line	:	3030 FAIRVIEW
City	:	DETROIT
State	:	MI
Zip	:	48214
Country	:	US
Telephone Number	:	313-866-4500
Fax Number	:

Provider Business Practice Location Address
First Line	:	SOUTHEASTERN HIGH SCHOOL
Second Line	:	3030 FAIRVIEW
City	:	DETROIT
State	:	MI
Zip	:	48214
Country	:	US
Telephone Number	:	313-866-4500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2022
Last Update Date	:	08/03/2022

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