Provider Demographics
NPI:1730729369
Name:MITCHELL, TYLER ISSAC (CDCA1)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:ISSAC
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:CDCA1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1978 GARDEN LN APT 3
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45237-6045
Mailing Address - Country:US
Mailing Address - Phone:513-708-7871
Mailing Address - Fax:
Practice Address - Street 1:1978 GARDEN LN APT 3
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45237-6045
Practice Address - Country:US
Practice Address - Phone:513-708-7871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-12
Last Update Date:2020-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YA0400X, 101Y00000X
OHCDCA1170914101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor