Provider Demographics
NPI:1629584578
Name:MITCHELL, TIMOTHY WILBUR JR (LCSWA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WILBUR
Last Name:MITCHELL
Suffix:JR
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 CLIFTON ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5008
Mailing Address - Country:US
Mailing Address - Phone:252-353-0100
Mailing Address - Fax:252-364-8117
Practice Address - Street 1:313 CLIFTON ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5008
Practice Address - Country:US
Practice Address - Phone:252-353-0100
Practice Address - Fax:252-364-8117
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0120511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty