Provider Demographics
NPI:1518198746
Name:MITCHAM, MICHELLE A (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:A
Last Name:MITCHAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4032 MCLAUGHLIN DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-2759
Mailing Address - Country:US
Mailing Address - Phone:813-777-4028
Mailing Address - Fax:
Practice Address - Street 1:3035 ELIZA RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-6243
Practice Address - Country:US
Practice Address - Phone:813-777-4028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YP2500X
FLMH12147101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional