Provider Demographics
NPI:1407278609
Name:MITCHELL, EMILY LOUISE (MA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:LOUISE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2852 NACOMA PL
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45420-3841
Mailing Address - Country:US
Mailing Address - Phone:513-417-5529
Mailing Address - Fax:
Practice Address - Street 1:819 COLORADO DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-4859
Practice Address - Country:US
Practice Address - Phone:937-562-9706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.11565235Z00000X
OHCOND.2014159-SP390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0400470Medicaid