Healthcare Provider Details

I. General information

NPI: 1932460912
Provider Name (Legal Business Name): MARY LINNEA MITCHELL MSW, LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY LINNEA MITCHELL LMSW

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 11/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 SHELDON BLVD SE STE 100
GRAND RAPIDS MI
49503-4224
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 606-391-6120
  • Fax:
Mailing address:
  • Phone: 616-486-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6802085295
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: