Healthcare Provider Details

I. General information

NPI: 1164520888
Provider Name (Legal Business Name): LYNDA M MITCHELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 COUNTY ROAD 3914
BULLARD TX
75757-6820
US

IV. Provider business mailing address

3618 LONG LEAF DR
TYLER TX
75707
US

V. Phone/Fax

Practice location:
  • Phone: 903-894-6000
  • Fax:
Mailing address:
  • Phone: 903-565-4636
  • Fax: 903-565-4559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number35162
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: