Provider Demographics
NPI:1275847337
Name:MITTEN, KENNETH CARL (LCSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:CARL
Last Name:MITTEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4057 FAIRWAY VIEW CIR W
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135-9124
Mailing Address - Country:US
Mailing Address - Phone:901-384-9732
Mailing Address - Fax:662-890-0622
Practice Address - Street 1:6810 CRUMPLER BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1933
Practice Address - Country:US
Practice Address - Phone:901-483-9548
Practice Address - Fax:662-890-0622
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-31
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC69181041C0700X
TN43331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical