Provider Demographics
NPI:1124265491
Name:MITCHELL, MARISSA (LMFT)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 MCANDREWS RD W STE 227
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4447
Mailing Address - Country:US
Mailing Address - Phone:952-892-8402
Mailing Address - Fax:
Practice Address - Street 1:1500 MCANDREWS RD W STE 227
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4447
Practice Address - Country:US
Practice Address - Phone:952-892-8402
Practice Address - Fax:952-892-8402
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1709106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1124265491Medicaid