Healthcare Provider Details

I. General information

NPI: 1508989237
Provider Name (Legal Business Name): GWEN E. MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 W 3RD ST
MOSCOW ID
83843-2268
US

IV. Provider business mailing address

420 SUMMIT RD
MOSCOW ID
83843-9651
US

V. Phone/Fax

Practice location:
  • Phone: 208-885-3588
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: