Provider Demographics
NPI:1285939934
Name:MITCHAM, CHRISTINA MARIE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:MARIE
Last Name:MITCHAM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MRS
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:MITCHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:40 JEFFERSON AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4304
Mailing Address - Country:US
Mailing Address - Phone:616-456-1443
Mailing Address - Fax:616-732-6392
Practice Address - Street 1:40 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4304
Practice Address - Country:US
Practice Address - Phone:616-456-1443
Practice Address - Fax:616-732-6392
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801088032104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker