Provider Demographics
NPI:1376641415
Name:MITCHELL, COREY J (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:J
Last Name:MITCHELL
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Gender:M
Credentials:MA, CCC-SLP
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Mailing Address - Street 1:1030 N ROGERS LN
Mailing Address - Street 2:SUITE 107-15
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-6083
Mailing Address - Country:US
Mailing Address - Phone:919-332-7591
Mailing Address - Fax:186-659-3892
Practice Address - Street 1:704 WHITE DAISIES CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-2187
Practice Address - Country:US
Practice Address - Phone:919-332-7591
Practice Address - Fax:186-659-3892
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-09-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC5615235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412467Medicaid