Healthcare Provider Details

I. General information

NPI: 1457602062
Provider Name (Legal Business Name): CASSANDRA DIANNE MITCHELL LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17826 NEW HAMPSHIRE AVE
ASHTON MD
20861-9781
US

IV. Provider business mailing address

99 TRUCK HOUSE RD
SEVERNA PARK MD
21146-2738
US

V. Phone/Fax

Practice location:
  • Phone: 800-491-5369
  • Fax: 301-774-3678
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP4554
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: