MEDICARE: EBONY MITCHELL

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	171M00000X	Case Manager/Care Coordinator
2	104100000X	Social Worker
3	1041C0700X	Clinical Social Worker
4	390200000X	Student in an Organized Health Care Education/Training Program
5	1041S0200X	School Social Worker	W.2000226	OH

General Provider Information

NPI Number	:	1851884720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY MITCHELL

Provider Business Mailing Address
First Line	:	2611 WAYNE AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45420-1833
Country	:	US
Telephone Number	:	937-641-8554
Fax Number	:	877-938-3265

Provider Business Practice Location Address
First Line	:	1020 WOODMAN DR STE 330
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45432-1410
Country	:	US
Telephone Number	:	937-253-0606
Fax Number	:	877-938-3265

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

Provider Enumeration Date	:	06/14/2018
Last Update Date	:	03/05/2026

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