Provider Demographics
NPI:1770946667
Name:MITCHELL, GLENDA LU (MS)
Entity type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:LU
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SHIPTON LN.
Mailing Address - Street 2:
Mailing Address - City:FT. WASHAKIE
Mailing Address - State:WY
Mailing Address - Zip Code:82514
Mailing Address - Country:US
Mailing Address - Phone:307-335-1169
Mailing Address - Fax:
Practice Address - Street 1:7 SHIPTON LN.
Practice Address - Street 2:
Practice Address - City:FT. WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514
Practice Address - Country:US
Practice Address - Phone:307-335-1169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCAPA-060172V00000X
172V00000X
WYPPC1235101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No172V00000XOther Service ProvidersCommunity Health Worker