Provider Demographics
NPI:1790484830
Name:MITCHELL, ALTHEA
Entity Type:Individual
Prefix:
First Name:ALTHEA
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SPRING ST STE 205
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3757
Mailing Address - Country:US
Mailing Address - Phone:318-670-3170
Mailing Address - Fax:318-670-3607
Practice Address - Street 1:800 SPRING ST STE 205
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-3757
Practice Address - Country:US
Practice Address - Phone:318-670-3170
Practice Address - Fax:318-670-3607
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
TX101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty