Provider Demographics
NPI:1164619052
Name:MITCHELL, GLENDA K (BA, PSRS)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:K
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:BA, PSRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 SE AVE D
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-6204
Mailing Address - Country:US
Mailing Address - Phone:580-286-8930
Mailing Address - Fax:580-286-5185
Practice Address - Street 1:17 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-4625
Practice Address - Country:US
Practice Address - Phone:580-286-5184
Practice Address - Fax:580-286-5185
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist