=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982328894
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTEN MITCHELL LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2022
-----------------------------------------------------
Last Update Date | 09/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 686 BEAR SWAMP RD
-----------------------------------------------------
City | PERU
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12972-4804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-595-8168
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 260
-----------------------------------------------------
City | PERU
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12972-0260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-595-8168
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------