Provider Demographics
NPI:1134292667
Name:MITCHELL, WARREN (LCSW)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5295 SILVER CREEK DR SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-5359
Mailing Address - Country:US
Mailing Address - Phone:770-882-4240
Mailing Address - Fax:770-807-8161
Practice Address - Street 1:1841 MONTREAL RD
Practice Address - Street 2:SUITE 222
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5712
Practice Address - Country:US
Practice Address - Phone:770-882-4240
Practice Address - Fax:770-807-8161
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0035541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA185548077AMedicaid