=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275847337
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH CARL MITTEN LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2010
-----------------------------------------------------
Last Update Date | 08/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6810 CRUMPLER BLVD SUITE 303
-----------------------------------------------------
City | OLIVE BRANCH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38654-1933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-483-9548
-----------------------------------------------------
Fax | 662-890-0622
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4057 FAIRWAY VIEW CIR W
-----------------------------------------------------
City | BARTLETT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38135-9124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-384-9732
-----------------------------------------------------
Fax | 662-890-0622
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C6918
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 4333
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------