MEDICARE: DR. CHANTE WELLINGTON MITCHELL PH.D.

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	103TC0700X	Clinical Psychologist	PSY004393	GA

General Provider Information

NPI Number	:	1073767174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHANTE WELLINGTON MITCHELL PH.D.

Provider Business Mailing Address
First Line	:	2400 PLEASANT HILL RD STE 165
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-1702
Country	:	US
Telephone Number	:	770-476-1967
Fax Number	:	770-476-0377

Provider Business Practice Location Address
First Line	:	2400 PLEASANT HILL RD STE 165
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-1702
Country	:	US
Telephone Number	:	412-609-7550
Fax Number	:	770-476-0377

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

Provider Enumeration Date	:	11/17/2008
Last Update Date	:	07/31/2021

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