Healthcare Provider Details

I. General information

NPI: 1366940769
Provider Name (Legal Business Name): THAIS LYNN MITCHELL LMSW, CASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 OLD ROUTE 6
CARMEL NY
10512-2107
US

IV. Provider business mailing address

79 GLENRIDGE RD
GLENVILLE NY
12302-4523
US

V. Phone/Fax

Practice location:
  • Phone: 845-225-5202
  • Fax: 845-704-6178
Mailing address:
  • Phone: 518-952-8408
  • Fax: 518-399-6860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number097428
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number097428
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number097428
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: