Provider Demographics
NPI:1225248461
Name:MITCHELL, DIANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 REYNOLDA VLG
Mailing Address - Street 2:SUITE G
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-5126
Mailing Address - Country:US
Mailing Address - Phone:336-761-8600
Mailing Address - Fax:
Practice Address - Street 1:121 REYNOLDA VLG
Practice Address - Street 2:SUITE G
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-5126
Practice Address - Country:US
Practice Address - Phone:336-761-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC966103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC04143OtherBLUE CROSS BLUE SHIELD OF NORTH CAROLINA