Provider Demographics
NPI:1003085432
Name:MITCHUM, NIA-SUE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:NIA-SUE
Middle Name:
Last Name:MITCHUM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ASPEN ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-2201
Mailing Address - Country:US
Mailing Address - Phone:617-427-3312
Mailing Address - Fax:
Practice Address - Street 1:3 ASPEN ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-2201
Practice Address - Country:US
Practice Address - Phone:617-427-3312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1041431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical