MEDICARE: DR. MICHELLE D. 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	PSY002833	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10044615	OTHER	GA	AMERIGROUP PRACTITIONER #

General Provider Information

NPI Number	:	1922213974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHELLE D. MITCHELL PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 725575
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	31139-2575
Country	:	US
Telephone Number	:	404-516-1996
Fax Number	:	678-309-3730

Provider Business Practice Location Address
First Line	:	3480 GREENBRIAR PKWY SW STE 230
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-3123
Country	:	US
Telephone Number	:	404-516-1996
Fax Number	:	678-309-3730

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

Provider Enumeration Date	:	05/13/2007
Last Update Date	:	07/09/2007

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