Healthcare Provider Details

I. General information

NPI: 1548311541
Provider Name (Legal Business Name): TERRY LYNN MITCHELL MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PIERCE ST
SAN FRANCISCO CA
94115-4005
US

IV. Provider business mailing address

1057 N SHELTER BAY
HERCULES CA
94547-2609
US

V. Phone/Fax

Practice location:
  • Phone: 415-563-8200
  • Fax: 415-563-5985
Mailing address:
  • Phone: 510-593-5536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberM0503032055
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: