MEDICARE: KAILIE N MITCHELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CDCA.193187	OH

General Provider Information

NPI Number	:	1053297879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAILIE N MITCHELL

Provider Business Mailing Address
First Line	:	135 PARK AVE APT 25
Second Line	:
City	:	PLYMOUTH
State	:	OH
Zip	:	44865-1239
Country	:	US
Telephone Number	:	419-554-4066
Fax Number	:

Provider Business Practice Location Address
First Line	:	177 MILAN AVE
Second Line	:
City	:	NORWALK
State	:	OH
Zip	:	44857-1131
Country	:	US
Telephone Number	:	567-743-7199
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2025
Last Update Date	:	08/15/2025

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