Provider Demographics
NPI:1649779927
Name:MITCHELL, LARRY (MA CAADC SPADA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MA CAADC SPADA
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA CAADC SPADA
Mailing Address - Street 1:1960 MILLBROOK ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-2636
Mailing Address - Country:US
Mailing Address - Phone:616-633-3700
Mailing Address - Fax:616-930-4640
Practice Address - Street 1:1960 MILLBROOK ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-2636
Practice Address - Country:US
Practice Address - Phone:616-633-3700
Practice Address - Fax:616-930-4640
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-00112101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty