Provider Demographics
NPI:1275011215
Name:MITCHELL, TIARA MARQUE (LCSW-A)
Entity Type:Individual
Prefix:MRS
First Name:TIARA
Middle Name:MARQUE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1004
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28359-1004
Mailing Address - Country:US
Mailing Address - Phone:910-964-0678
Mailing Address - Fax:910-738-1451
Practice Address - Street 1:3581 LACKEY ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28360-9048
Practice Address - Country:US
Practice Address - Phone:910-738-5023
Practice Address - Fax:910-738-1451
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-10-10
Deactivation Date:2018-08-13
Deactivation Code:
Reactivation Date:2018-10-10
Provider Licenses
StateLicense IDTaxonomies
NCP0125651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical