Healthcare Provider Details

I. General information

NPI: 1144547720
Provider Name (Legal Business Name): MATTHEW SHANE MITCHELL L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2010
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 FOOTE ST
CORINTH MS
38834-4834
US

IV. Provider business mailing address

PO BOX 839
CORINTH MS
38835-0839
US

V. Phone/Fax

Practice location:
  • Phone: 662-287-4424
  • Fax: 662-287-7020
Mailing address:
  • Phone: 662-728-2185
  • Fax: 662-728-2345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: