Healthcare Provider Details

I. General information

NPI: 1205395167
Provider Name (Legal Business Name): MITRA SELL LCSW, LEP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5570 E BIG SKY LN
ANAHEIM CA
92807-4644
US

IV. Provider business mailing address

5570 E BIG SKY LN
ANAHEIM CA
92807-4644
US

V. Phone/Fax

Practice location:
  • Phone: 714-745-2779
  • Fax:
Mailing address:
  • Phone: 714-745-2779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLEP2889
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS20902
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: