=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831471184
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORENNA MARIE MITCHAM LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2011
-----------------------------------------------------
Last Update Date | 06/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 TYDD ST
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-441-1624
-----------------------------------------------------
Fax | 707-441-1253
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 670 9TH STREET SUITE 203
-----------------------------------------------------
City | ARCATA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95521-6249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-826-8633
-----------------------------------------------------
Fax | 707-826-8638
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171000000X
-----------------------------------------------------
Taxonomy Name | Military Health Care Provider
-----------------------------------------------------
License Number | 26524
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW26524
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------