Provider Demographics
NPI:1225173644
Name:MITCHELL, TARA L (LPC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 UNITED WAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FREDERIC
Mailing Address - State:WI
Mailing Address - Zip Code:54837-8938
Mailing Address - Country:US
Mailing Address - Phone:715-327-4402
Mailing Address - Fax:715-327-8509
Practice Address - Street 1:203 UNITED WAY DRIVE
Practice Address - Street 2:
Practice Address - City:FREDERIC
Practice Address - State:WI
Practice Address - Zip Code:54837-8938
Practice Address - Country:US
Practice Address - Phone:715-327-4402
Practice Address - Fax:715-327-8509
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3728-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40969600Medicaid
MN7C790MIOtherBCBS OF MN
WIHP83841OtherHEALTH PARTNERS
MN7C790MIOtherBCBS OF MN