Provider Demographics
NPI:1104224401
Name:MITCHELL, TAMARA (MA ED S)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MA ED S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1436
Mailing Address - Country:US
Mailing Address - Phone:304-528-5019
Mailing Address - Fax:304-528-5136
Practice Address - Street 1:2850 5TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1436
Practice Address - Country:US
Practice Address - Phone:304-528-5019
Practice Address - Fax:304-528-5136
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool