=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205079753
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGE WINSTON MITCHELL LMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2009
-----------------------------------------------------
Last Update Date | 04/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1621 N DIXIE HWY
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33305-3138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-592-7891
-----------------------------------------------------
Fax | 954-429-8890
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1621 N DIXIE HWY
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33305-3138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-592-7891
-----------------------------------------------------
Fax | 954-429-8890
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 1602
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 15597
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH7499
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------