Healthcare Provider Details

I. General information

NPI: 1760261572
Provider Name (Legal Business Name): DUVONE MITCHELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2023
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 MADISON ST STE 502
WORCESTER MA
01608-2058
US

IV. Provider business mailing address

90 MADISON ST STE 502
WORCESTER MA
01608-2058
US

V. Phone/Fax

Practice location:
  • Phone: 774-530-6363
  • Fax: 774-530-6364
Mailing address:
  • Phone: 774-530-6363
  • Fax: 774-530-6364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: