Healthcare Provider Details

I. General information

NPI: 1043859614
Provider Name (Legal Business Name): AUDREY MITCHELL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2019
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4070 LAKE DRIVE SE SUITE 101
GRAND RAPIDS MI
49546-4954
US

IV. Provider business mailing address

547 92ND ST SE
BYRON CENTER MI
49315
US

V. Phone/Fax

Practice location:
  • Phone: 616-426-9869
  • Fax:
Mailing address:
  • Phone: 616-426-9869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: AUDREY M MITCHELL
Title or Position: OWNER
Credential: LMSW
Phone: 616-426-9869