Provider Demographics
NPI:1902895840
Name:MITCHELL, CHARLIE RAYMOND (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:RAYMOND
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 N IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85220-3830
Mailing Address - Country:US
Mailing Address - Phone:480-982-2356
Mailing Address - Fax:480-982-2449
Practice Address - Street 1:288 N IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85220-3830
Practice Address - Country:US
Practice Address - Phone:480-982-2356
Practice Address - Fax:480-982-2449
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1112103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist