Provider Demographics
NPI:1689199143
Name:MITCHELL, CHARLES (LCDP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 CAMINO DIABLO STE 105
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-3945
Mailing Address - Country:US
Mailing Address - Phone:800-892-2695
Mailing Address - Fax:
Practice Address - Street 1:10 DORRANCE ST STE 700
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-2014
Practice Address - Country:US
Practice Address - Phone:800-892-2695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00719101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)