Provider Demographics
NPI:1962551853
Name:MITCHELL, ELIZABETH ROWE (LP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ROWE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 JAMES AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2114
Mailing Address - Country:US
Mailing Address - Phone:651-698-3122
Mailing Address - Fax:
Practice Address - Street 1:4530 W 77TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55435-5006
Practice Address - Country:US
Practice Address - Phone:763-515-2453
Practice Address - Fax:763-515-2442
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 1336103TB0200X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN960053100Medicaid