Healthcare Provider Details

I. General information

NPI: 1962163907
Provider Name (Legal Business Name): TARA NICOLE MITCHELL LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 01/03/2022
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 ANNAPOLIS RD
ODENTON MD
21113-1344
US

IV. Provider business mailing address

9524 WANDERING WAY
COLUMBIA MD
21045-3243
US

V. Phone/Fax

Practice location:
  • Phone: 410-975-0067
  • Fax:
Mailing address:
  • Phone: 301-793-5160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC12208
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC12208
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: