Provider Demographics
NPI:1093289530
Name:MITCHELL, CARISSA MARIE (BA, CT)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:MARIE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:BA, CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 WOODMAN DR STE 330
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45432-1410
Mailing Address - Country:US
Mailing Address - Phone:937-253-0606
Mailing Address - Fax:
Practice Address - Street 1:1020 WOODMAN DR STE 330
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-1410
Practice Address - Country:US
Practice Address - Phone:937-253-0606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2002974101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional