Provider Demographics
NPI:1144503319
Name:COREY J MITCHELL LLC
Entity type:Organization
Organization Name:COREY J MITCHELL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:919-332-7591
Mailing Address - Street 1:1030 N ROGERS LN
Mailing Address - Street 2:SUITE 107-15
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-6083
Mailing Address - Country:US
Mailing Address - Phone:919-332-7591
Mailing Address - Fax:866-593-8924
Practice Address - Street 1:704 WHITE DAISIES CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-2187
Practice Address - Country:US
Practice Address - Phone:919-332-7591
Practice Address - Fax:866-593-8924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5615235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1376641415OtherNPPES 1-INDIVIDUAL
NC7412467Medicaid