Provider Demographics
NPI:1598259558
Name:MITTON, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:MITTON
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 1:2853 CROCKETT ST APT 307
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2993
Mailing Address - Country:US
Mailing Address - Phone:940-367-1471
Mailing Address - Fax:
Practice Address - Street 1:2853 CROCKETT ST APT 307
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2993
Practice Address - Country:US
Practice Address - Phone:940-367-1471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2023-08-07
Deactivation Date:2023-06-11
Deactivation Code:
Reactivation Date:2023-06-29
Provider Licenses
StateLicense IDTaxonomies
TX88003101YM0800X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician