Healthcare Provider Details

I. General information

NPI: 1396690772
Provider Name (Legal Business Name): DEVANTE MITCHELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2026
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19300 STOCKTON AVE
MAPLE HEIGHTS OH
44137-2367
US

IV. Provider business mailing address

19300 STOCKTON AVE
MAPLE HEIGHTS OH
44137-2367
US

V. Phone/Fax

Practice location:
  • Phone: 216-532-9672
  • Fax:
Mailing address:
  • Phone: 216-532-9672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberTV498705
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: