Healthcare Provider Details

I. General information

NPI: 1457556011
Provider Name (Legal Business Name): RICKY DONALD MITCHELL CSAC, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 NORTH ST
BRISTOL VA
24201-3275
US

IV. Provider business mailing address

PO BOX 352
ABINGDON VA
24212-0352
US

V. Phone/Fax

Practice location:
  • Phone: 276-254-5445
  • Fax: 276-208-8045
Mailing address:
  • Phone: 276-254-5445
  • Fax: 276-206-8045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0701003539
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701003539
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: