Provider Demographics
NPI:1679069579
Name:MEDLEY, MITCHELL DEWAYNE
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DEWAYNE
Last Name:MEDLEY
Suffix:
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 1:1721 WESTWIND DR
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-3026
Mailing Address - Country:US
Mailing Address - Phone:661-431-1466
Mailing Address - Fax:661-834-5423
Practice Address - Street 1:7300 MING AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-3492
Practice Address - Country:US
Practice Address - Phone:661-834-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-15-18048103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst