Provider Demographics
NPI:1730564097
Name:MITCHELL, CHRYSTAL (MS, LPC)
Entity type:Individual
Prefix:
First Name:CHRYSTAL
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 CALVIN DEES ST
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-2519
Mailing Address - Country:US
Mailing Address - Phone:601-528-1527
Mailing Address - Fax:
Practice Address - Street 1:3407 SHAMROCK CT
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5337
Practice Address - Country:US
Practice Address - Phone:228-497-0690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2019-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2400101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid