Provider Demographics
NPI:1376919878
Name:MITCHELL, TINA
Entity Type:Individual
Prefix:MRS
First Name:TINA
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 1:10075 HIGHWAY 51
Mailing Address - Street 2:
Mailing Address - City:BROSELEY
Mailing Address - State:MO
Mailing Address - Zip Code:63932
Mailing Address - Country:US
Mailing Address - Phone:573-718-9909
Mailing Address - Fax:
Practice Address - Street 1:10075 HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:BROSELEY
Practice Address - State:MO
Practice Address - Zip Code:63932-9276
Practice Address - Country:US
Practice Address - Phone:573-718-9909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator