Provider Demographics
NPI:1285653238
Name:MITCHELL, MARILYN SUE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:SUE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11020 N TATUM BLVD
Mailing Address - Street 2:STE.100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6072
Mailing Address - Country:US
Mailing Address - Phone:602-996-8619
Mailing Address - Fax:602-996-7932
Practice Address - Street 1:11020 N TATUM BLVD
Practice Address - Street 2:STE.100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6072
Practice Address - Country:US
Practice Address - Phone:602-996-8619
Practice Address - Fax:602-996-7932
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1159103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ76244Medicare PIN