Provider Demographics
NPI:1346974888
Name:MITCHELL, SHANTORIUS
Entity Type:Individual
Prefix:
First Name:SHANTORIUS
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 JAY ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:GA
Mailing Address - Zip Code:30293-3506
Mailing Address - Country:US
Mailing Address - Phone:678-416-5221
Mailing Address - Fax:
Practice Address - Street 1:1565 HIGHWAY 34 E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2401
Practice Address - Country:US
Practice Address - Phone:877-288-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-224154106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician