Healthcare Provider Details

I. General information

NPI: 1205231834
Provider Name (Legal Business Name): AUDREY A MITCHELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 W AMERICANA TER STE 210B
BOISE ID
83706-2521
US

IV. Provider business mailing address

4863 S GREENACRES WAY
BOISE ID
83709-5276
US

V. Phone/Fax

Practice location:
  • Phone: 208-402-6325
  • Fax:
Mailing address:
  • Phone: 208-713-5454
  • Fax: 208-706-7059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34098
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: