Provider Demographics
NPI:1376974584
Name:MITCHELL, KENNETH (DMGMT)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DMGMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 W CLUB BLVD
Mailing Address - Street 2:SUITE 6-661
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-1104
Mailing Address - Country:US
Mailing Address - Phone:919-416-1736
Mailing Address - Fax:919-416-1729
Practice Address - Street 1:517 TODD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-1823
Practice Address - Country:US
Practice Address - Phone:919-416-1736
Practice Address - Fax:919-416-1729
Is Sole Proprietor?:No
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF05850171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator