Provider Demographics
NPI:1114696937
Name:MITCHELL, CHANNON MELLISA
Entity Type:Individual
Prefix:
First Name:CHANNON
Middle Name:MELLISA
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 N PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1904
Mailing Address - Country:US
Mailing Address - Phone:310-912-9274
Mailing Address - Fax:
Practice Address - Street 1:145 N PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1904
Practice Address - Country:US
Practice Address - Phone:310-912-9274
Practice Address - Fax:323-545-3156
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20202008Medicaid