Provider Demographics
NPI:1407404437
Name:MITCHELL, BROOKLYN
Entity Type:Individual
Prefix:
First Name:BROOKLYN
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 1:1201 CENTRAL AVE APT 433
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2593
Mailing Address - Country:US
Mailing Address - Phone:330-209-7118
Mailing Address - Fax:
Practice Address - Street 1:1595 LEWIS RD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29154-7351
Practice Address - Country:US
Practice Address - Phone:704-289-0720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No372600000XNursing Service Related ProvidersAdult Companion