Provider Demographics
NPI:1740393735
Name:MITCHELL, WILLIAM EDGEFIELD III (PSYD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:EDGEFIELD
Last Name:MITCHELL
Suffix:III
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 ELMWOOD AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3602
Mailing Address - Country:US
Mailing Address - Phone:585-465-5072
Mailing Address - Fax:585-486-5077
Practice Address - Street 1:1595 ELMWOOD AVE STE 2
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3602
Practice Address - Country:US
Practice Address - Phone:585-465-5072
Practice Address - Fax:585-486-5077
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011107103T00000X, 103TC2200X
NY0111107103T00000X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY103283EUOtherPREFERRED CARE
NY06800011107Medicaid
NYEMOtherEXCELLUS
NY014003729OtherEXCELLUS
NY3109089OtherVALUE OPTIONS
NY10613AMedicare ID - Type UnspecifiedUPSTATE MEDICARE