Provider Demographics
NPI:1417242009
Name:MITCHELL, ITASCA FAYE (MS)
Entity Type:Individual
Prefix:
First Name:ITASCA
Middle Name:FAYE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 RED ELM DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5610
Mailing Address - Country:US
Mailing Address - Phone:405-478-3429
Mailing Address - Fax:
Practice Address - Street 1:3035 NW 63RD ST STE 201
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-3606
Practice Address - Country:US
Practice Address - Phone:405-842-8801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health