Provider Demographics
NPI:1831471184
Name:MITCHAM, CORENNA MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CORENNA
Middle Name:MARIE
Last Name:MITCHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 9TH STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6249
Mailing Address - Country:US
Mailing Address - Phone:707-826-8633
Mailing Address - Fax:707-826-8638
Practice Address - Street 1:2200 TYDD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501
Practice Address - Country:US
Practice Address - Phone:707-441-1624
Practice Address - Fax:707-441-1253
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26524171000000X
CALCSW265241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171000000XOther Service ProvidersMilitary Health Care Provider