Provider Demographics
NPI:1629503982
Name:MITCHELL, SHAWN I
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:MITCHELL
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 UTAH ST
Mailing Address - Street 2:
Mailing Address - City:AVERY
Mailing Address - State:TX
Mailing Address - Zip Code:75554-2600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:508 N 2ND ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-3925
Practice Address - Country:US
Practice Address - Phone:870-455-0134
Practice Address - Fax:870-277-2230
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1675101YA0400X
175T00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist