Provider Demographics
NPI:1043859614
Name:AUDREY MITCHELL, LLC
Entity Type:Organization
Organization Name:AUDREY MITCHELL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-426-9869
Mailing Address - Street 1:547 92ND ST SE
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315
Mailing Address - Country:US
Mailing Address - Phone:616-426-9869
Mailing Address - Fax:
Practice Address - Street 1:4070 LAKE DRIVE SE
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-4954
Practice Address - Country:US
Practice Address - Phone:616-426-9869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)