Provider Demographics
NPI:1144933854
Name:MITCHELL, CARVINA VADOLL (BS, MS)
Entity type:Individual
Prefix:MISS
First Name:CARVINA
Middle Name:VADOLL
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:BS, MS
Other - Prefix:MISS
Other - First Name:KOURTNEY
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, MA
Mailing Address - Street 1:151 BROADWAY ST APT I1
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4813
Mailing Address - Country:US
Mailing Address - Phone:662-639-0067
Mailing Address - Fax:
Practice Address - Street 1:604 HIGHWAY 80 W STE R
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4108
Practice Address - Country:US
Practice Address - Phone:601-473-2106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MS171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator