Healthcare Provider Details

I. General information

NPI: 1083658173
Provider Name (Legal Business Name): MICHELE A. MITCHELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FREEDOM WAY 26
AUGUSTA GA
30904-6258
US

IV. Provider business mailing address

4530 GLENNWOOD DR
EVANS GA
30809-3222
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-0188
  • Fax: 706-731-7190
Mailing address:
  • Phone: 706-733-0188
  • Fax: 706-731-7190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3271
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: