Healthcare Provider Details

I. General information

NPI: 1982928123
Provider Name (Legal Business Name): MELISSA BUNNELL MITCHELL MSW, LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELISSA LYNN BUNNELL MSW, LISW

II. Dates (important events)

Enumeration Date: 03/17/2010
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 BACA ST SUITE D
SANTA FE NM
87505-0972
US

IV. Provider business mailing address

23 BOSQUE LOOP
SANTA FE NM
87508-2231
US

V. Phone/Fax

Practice location:
  • Phone: 505-920-8868
  • Fax:
Mailing address:
  • Phone: 505-920-8868
  • Fax: 505-466-1029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-3296
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: