Provider Demographics
NPI:1417207739
Name:MITCHELL, TRISTIAN E (LCSW)
Entity Type:Individual
Prefix:
First Name:TRISTIAN
Middle Name:E
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 470605
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-9305
Mailing Address - Country:US
Mailing Address - Phone:310-363-2724
Mailing Address - Fax:
Practice Address - Street 1:302 E MANCHESTER BLVD STE 203
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1815
Practice Address - Country:US
Practice Address - Phone:103-363-2724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA794481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical