Provider Demographics
NPI:1609266717
Name:MITCHELL, RAMA JR (SUDP)
Entity Type:Individual
Prefix:
First Name:RAMA
Middle Name:
Last Name:MITCHELL
Suffix:JR
Gender:M
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2509
Mailing Address - Country:US
Mailing Address - Phone:360-425-9210
Mailing Address - Fax:360-501-6131
Practice Address - Street 1:621 GRADE ST
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-2606
Practice Address - Country:US
Practice Address - Phone:360-425-9210
Practice Address - Fax:360-501-6131
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00004525101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2087502Medicaid