MEDICARE: DR. NATHANAEL 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	103T00000X	Psychologist	KY-1624	KY

General Provider Information

NPI Number	:	1700131703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NATHANAEL MITCHELL

Provider Business Mailing Address
First Line	:	845 S 3RD ST
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40203-2213
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6511 GLENRIDGE PARK PL
Second Line	:	SUITE 5
City	:	LOUISVILLE
State	:	KY
Zip	:	40222-3452
Country	:	US
Telephone Number	:	502-614-7600
Fax Number	:

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

Provider Enumeration Date	:	07/17/2012
Last Update Date	:	07/17/2012

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