Provider Demographics
NPI:1619389632
Name:MITCHELL, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:MITCHELL
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 1:6700 ANTIOCH RD
Mailing Address - Street 2:
Mailing Address - City:MERRIAM
Mailing Address - State:KS
Mailing Address - Zip Code:66204-1497
Mailing Address - Country:US
Mailing Address - Phone:816-914-4092
Mailing Address - Fax:
Practice Address - Street 1:6700 ANTIOCH RD
Practice Address - Street 2:
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-1497
Practice Address - Country:US
Practice Address - Phone:816-914-4092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-26
Last Update Date:2014-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003029512235Z00000X
KS3192235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist