Provider Demographics
NPI:1548470776
Name:DIANNE MITCHELL, PH.D., PLLC
Entity type:Organization
Organization Name:DIANNE MITCHELL, PH.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:336-761-8600
Mailing Address - Street 1:121 REYNOLDA VLG
Mailing Address - Street 2:SUITE G
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-5126
Mailing Address - Country:US
Mailing Address - Phone:336-761-8600
Mailing Address - Fax:336-725-8550
Practice Address - Street 1:121 REYNOLDA VLG
Practice Address - Street 2:SUITE G
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-5126
Practice Address - Country:US
Practice Address - Phone:336-761-8600
Practice Address - Fax:336-725-8550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC04143OtherBLUE CROSS BLUE SHIELD OF NORTH CAROLINA