Provider Demographics
NPI:1508563081
Name:MITCHELL, MARK J
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:MITCHELL
Suffix:
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 1:8055 W MANCHESTER AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-7962
Mailing Address - Country:US
Mailing Address - Phone:310-822-7979
Mailing Address - Fax:
Practice Address - Street 1:8055 W MANCHESTER AVE STE 200
Practice Address - Street 2:
Practice Address - City:PLAYA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90293-7962
Practice Address - Country:US
Practice Address - Phone:310-822-7979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMP19638101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health