Healthcare Provider Details

I. General information

NPI: 1114696937
Provider Name (Legal Business Name): CHANNON MELLISA MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 N PRAIRIE AVE
INGLEWOOD CA
90301-1904
US

IV. Provider business mailing address

145 N PRAIRIE AVE
INGLEWOOD CA
90301-1904
US

V. Phone/Fax

Practice location:
  • Phone: 310-912-9274
  • Fax: 323-545-3156
Mailing address:
  • Phone: 310-912-9274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: