Provider Demographics
NPI:1710245030
Name:REID, MITCHELL C (LCP)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:C
Last Name:REID
Suffix:
Gender:M
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3036 WADDINGTON DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23224-5724
Mailing Address - Country:US
Mailing Address - Phone:804-343-7646
Mailing Address - Fax:804-819-5221
Practice Address - Street 1:3036 WADDINGTON DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23224-5724
Practice Address - Country:US
Practice Address - Phone:804-343-7646
Practice Address - Fax:804-819-5221
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004560103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical