Provider Demographics
NPI:1558807578
Name:MITCHELL, COURTNEY (MED,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 PALISADES PLACE DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-6146
Mailing Address - Country:US
Mailing Address - Phone:404-244-9477
Mailing Address - Fax:855-204-3767
Practice Address - Street 1:4153 FLAT SHOALS PKWY
Practice Address - Street 2:BUILDING C SUITE 300A
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-4106
Practice Address - Country:US
Practice Address - Phone:404-244-9477
Practice Address - Fax:855-204-3767
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-14
Last Update Date:2017-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009536235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist