Healthcare Provider Details

I. General information

NPI: 1396306023
Provider Name (Legal Business Name): EMMA MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 02/09/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6610 S WISCONSIN AVE
GAYLORD MI
49735
US

IV. Provider business mailing address

4475 DENNIS AVE
LEWISTON MI
49756-8885
US

V. Phone/Fax

Practice location:
  • Phone: 231-268-0336
  • Fax:
Mailing address:
  • Phone: 228-341-0303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401001001
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: