Provider Demographics
NPI:1720086929
Name:MCBRIDE, MITZI SUZANNE (LCSW)
Entity type:Individual
Prefix:
First Name:MITZI
Middle Name:SUZANNE
Last Name:MCBRIDE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPARTMENT 888182
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37995-8182
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:119 PEDIGO ROAD
Practice Address - Street 2:SUITE F
Practice Address - City:MADISONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37354
Practice Address - Country:US
Practice Address - Phone:423-442-5280
Practice Address - Fax:423-442-8127
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNCSW62491041C0700X
TNLSW47401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3987500Medicaid
TN3987500Medicaid