Provider Demographics
NPI:1124786314
Name:MITCHELL, MARTHA DAVIDSON
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:DAVIDSON
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6306 BROCK CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2024
Mailing Address - Country:US
Mailing Address - Phone:601-405-3696
Mailing Address - Fax:
Practice Address - Street 1:6306 BROCK CIR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2024
Practice Address - Country:US
Practice Address - Phone:601-405-3696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-04
Last Update Date:2021-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator