Provider Demographics
NPI:1568759157
Name:MITCHELL, CHARLES MICHAEL (LPC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:CHARLIE
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:1590 SE N ST STE H
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-3905
Mailing Address - Country:US
Mailing Address - Phone:541-507-7896
Mailing Address - Fax:
Practice Address - Street 1:1215 SW G ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2544
Practice Address - Country:US
Practice Address - Phone:541-476-2373
Practice Address - Fax:541-476-1526
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2287101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional