Healthcare Provider Details

I. General information

NPI: 1073671996
Provider Name (Legal Business Name): MITCHELL DON BRIMAGE SR. PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MITCHELL DON BRIMAGE PMHNP-BC

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 06/06/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 BAY LAUREL PLACE SUITE 3B
AVILA BEACH CA
93424
US

IV. Provider business mailing address

1260 ELLA ST UNIT 8
SAN LUIS OBISPO CA
93401-4147
US

V. Phone/Fax

Practice location:
  • Phone: 805-459-8232
  • Fax:
Mailing address:
  • Phone: 805-441-3611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95019766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: