Provider Demographics
NPI:1902439490
Name:MITCHELL, TILLIE (LCSWA)
Entity Type:Individual
Prefix:
First Name:TILLIE
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 ARBORS DR APT A
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-6590
Mailing Address - Country:US
Mailing Address - Phone:714-833-7364
Mailing Address - Fax:
Practice Address - Street 1:199 LAKE RD
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:NC
Practice Address - Zip Code:28164-2312
Practice Address - Country:US
Practice Address - Phone:704-860-3501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0142441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty