Provider Demographics
NPI:1124560990
Name:MITCHELL, CHELISE
Entity Type:Individual
Prefix:
First Name:CHELISE
Middle Name:
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 1:1250 W GROVE PKWY
Mailing Address - Street 2:1014
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-4435
Mailing Address - Country:US
Mailing Address - Phone:602-810-4820
Mailing Address - Fax:
Practice Address - Street 1:1250 W GROVE PKWY
Practice Address - Street 2:1014
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-4435
Practice Address - Country:US
Practice Address - Phone:602-810-4820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-18825225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist