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General NPI Number Information
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NPI Number | 1922811249
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Entity Type | Individual
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Provider Name | ZACHARY WADE MITCHEM PRSS
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Gender | Male
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Dates
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Enumeration Date | 01/30/2025
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Last Update Date | 01/30/2025
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Provider Practice Location Address
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Address Line | 1514 KANAWHA BLVD W
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City | CHARLESTON
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State | WV
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Zip | 25387-2533
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Country | US
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Telephone | 304-646-9018
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Fax | 304-768-7647
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Provider Business Mailing Address
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Address Line | 1514 KANAWHA BLVD W ATTN ZACK MITCHEM
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City | CHARLESTON
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State | WV
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Zip | 25387-2533
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Country | US
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Telephone | 304-646-9018
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Fax | 304-768-7647
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | 25-902SUD
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License Number State | WV
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