Provider Demographics
NPI:1598859092
Name:MITCHUM, ALPHONSO (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ALPHONSO
Middle Name:
Last Name:MITCHUM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 CLINTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206
Mailing Address - Country:US
Mailing Address - Phone:518-626-5317
Mailing Address - Fax:518-626-5407
Practice Address - Street 1:113 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3410
Practice Address - Country:US
Practice Address - Phone:518-626-5162
Practice Address - Fax:518-462-3099
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069423-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical