Provider Demographics
NPI:1134474794
Name:MITROVICH, JOSEPH MICHAEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:MITROVICH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:STEILACOOM
Mailing Address - State:WA
Mailing Address - Zip Code:98388-1327
Mailing Address - Country:US
Mailing Address - Phone:253-514-2460
Mailing Address - Fax:
Practice Address - Street 1:1715 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:STEILACOOM
Practice Address - State:WA
Practice Address - Zip Code:98388-1327
Practice Address - Country:US
Practice Address - Phone:253-514-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
WAPY 60218793103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist