Healthcare Provider Details

I. General information

NPI: 1205804192
Provider Name (Legal Business Name): THOMAS POLLARD MITCHELL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 SANDPIPER DR
ST AUGUSTINE FL
32080-6987
US

IV. Provider business mailing address

21 SANDPIPER DR
ST AUGUSTINE FL
32080-6987
US

V. Phone/Fax

Practice location:
  • Phone: 914-475-7204
  • Fax: 904-461-1587
Mailing address:
  • Phone: 904-461-1587
  • Fax: 904-461-1587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW8040
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: