=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699893594
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLIVIA J MITCHELL PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 NEWPORT CENTER DR SUITE 202
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-7501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-497-8563
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 393 MYRTLE ST
-----------------------------------------------------
City | LAGUNA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92651-1532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-494-0632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY12382
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------