Provider Demographics
NPI:1376959130
Name:CRISWELL, MITCHELL DRAKE (DTCM, LIC AC)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DRAKE
Last Name:CRISWELL
Suffix:
Gender:M
Credentials:DTCM, LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 OLD US HIGHWAY 1 S
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-6341
Mailing Address - Country:US
Mailing Address - Phone:910-693-7905
Mailing Address - Fax:
Practice Address - Street 1:1150 OLD US HIGHWAY 1 S
Practice Address - Street 2:SUITE 3
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-6341
Practice Address - Country:US
Practice Address - Phone:910-693-7905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00043171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist