Provider Demographics
NPI:1609882646
Name:MITCHELL, DAVID RICHARD (MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:RICHARD
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 MAG WILLIAMS RD
Mailing Address - Street 2:
Mailing Address - City:CHICKAMAUGA
Mailing Address - State:GA
Mailing Address - Zip Code:30707-6039
Mailing Address - Country:US
Mailing Address - Phone:708-476-9192
Mailing Address - Fax:
Practice Address - Street 1:6098 DEBRA RD STE 5200
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-5702
Practice Address - Country:US
Practice Address - Phone:423-893-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0012641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149-001264OtherLCSW
IL36-3969618OtherFEDERAL TAX ID
ILL 2080-032716OtherTRICARE/CHAMPUS
IL049-72097OtherBLUE SHIELD PROVIDER #
IL060-006208OtherPRO. SERVICE CORP. LIC.#
ILL 2080-032716OtherTRICARE/CHAMPUS