Provider Demographics
NPI:1033101613
Name:MITCHELL, ROBERT JEFFERY SR (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JEFFERY
Last Name:MITCHELL
Suffix:SR
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:R.
Other - Middle Name:JEFFERY
Other - Last Name:MITCHELL
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:319 N OSAGE BLVD
Mailing Address - Street 2:PO BOX 766
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-2636
Mailing Address - Country:US
Mailing Address - Phone:417-667-3031
Mailing Address - Fax:417-667-3938
Practice Address - Street 1:319 N OSAGE BLVD
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-2636
Practice Address - Country:US
Practice Address - Phone:417-667-3031
Practice Address - Fax:417-667-3938
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPSY000669103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA595927AMedicare ID - Type UnspecifiedMEDICARE NUMBER