Provider Demographics
NPI: | 1467004648 |
---|---|
Name: | MITCHELL, ROBERT LEE JR |
Entity Type: | Individual |
Prefix: | MR |
First Name: | ROBERT |
Middle Name: | LEE |
Last Name: | MITCHELL |
Suffix: | JR |
Gender: | M |
Credentials: | |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 3326 MATHER FIELD RD |
Mailing Address - Street 2: | |
Mailing Address - City: | RANCHO CORDOVA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 95670-5966 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 916-368-7120 |
Mailing Address - Fax: | 916-368-7119 |
Practice Address - Street 1: | 3326 MATHER FIELD RD |
Practice Address - Street 2: | |
Practice Address - City: | RANCHO CORDOVA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 95670-5966 |
Practice Address - Country: | US |
Practice Address - Phone: | 916-368-7120 |
Practice Address - Fax: | 916-368-7119 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2019-07-09 |
Last Update Date: | 2020-11-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 6310 | 251S00000X |
251S00000X, 101YA0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No | 251S00000X | Agencies | Community/Behavioral Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 251S00000X | Other | ANGER MANAGEMENT AND 12 STEP CONSULTANT |