Provider Demographics
NPI:1720038060
Name:MITCHELL, CRAIG TULLIS (LCSW)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:TULLIS
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5922 S 2125 E
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5350
Mailing Address - Country:US
Mailing Address - Phone:801-476-1774
Mailing Address - Fax:
Practice Address - Street 1:5922 S 2125 E
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5350
Practice Address - Country:US
Practice Address - Phone:801-476-1774
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12532535011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical