Provider Demographics
NPI:1396403416
Name:MITCHAM, ALYSE
Entity Type:Individual
Prefix:
First Name:ALYSE
Middle Name:
Last Name:MITCHAM
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 1:20321 ARBOR AVE
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-3103
Mailing Address - Country:US
Mailing Address - Phone:216-407-3576
Mailing Address - Fax:
Practice Address - Street 1:20321 ARBOR AVE
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44123-3103
Practice Address - Country:US
Practice Address - Phone:216-407-3576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator