=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578789061
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN MARIE MITCHELL LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 KANSAS AVE SUITE B
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95351-1596
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-558-8884
-----------------------------------------------------
Fax | 209-558-8888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 KANSAS AVE SUITE B
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95351-1596
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-558-8884
-----------------------------------------------------
Fax | 209-558-8888
-----------------------------------------------------
=====================================================
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 | 16860
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------