Provider Demographics
NPI:1598396293
Name:MITCHENER, LACRESHA EDWINA
Entity Type:Individual
Prefix:
First Name:LACRESHA
Middle Name:EDWINA
Last Name:MITCHENER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CHEVERLY
Mailing Address - State:MD
Mailing Address - Zip Code:20785-1189
Mailing Address - Country:US
Mailing Address - Phone:301-857-2618
Mailing Address - Fax:
Practice Address - Street 1:3001 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785-1189
Practice Address - Country:US
Practice Address - Phone:301-357-5408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7041101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional