Provider Demographics
NPI:1629591136
Name:MITCHELL, ALISSA THEO (LMFT)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:THEO
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:THEO
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:283 OLD ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:ME
Mailing Address - Zip Code:04640-3443
Mailing Address - Country:US
Mailing Address - Phone:617-639-7912
Mailing Address - Fax:
Practice Address - Street 1:49 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3005
Practice Address - Country:US
Practice Address - Phone:207-299-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXM5423106H00000X
MEMF6559106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist