Provider Demographics
NPI:1699384511
Name:MITCHELL, MCKENNA
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
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 1:12713 SADDLE CLUB CIR APT 301
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33635-9684
Mailing Address - Country:US
Mailing Address - Phone:727-859-2577
Mailing Address - Fax:
Practice Address - Street 1:13139 W LINEBAUGH AVE STE 102
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-4498
Practice Address - Country:US
Practice Address - Phone:877-823-4283
Practice Address - Fax:352-332-8588
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-127991106S00000X
FL1-22-62793103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician