Healthcare Provider Details

I. General information

NPI: 1497205124
Provider Name (Legal Business Name): TAMARA MITCHELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

2108 E THOMAS RD
PHOENIX AZ
85016-7761
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-0414
  • Fax: 602-933-4252
Mailing address:
  • Phone: 602-933-3124
  • Fax: 949-595-0296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number28577
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-20305
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: