Provider Demographics
NPI:1881842318
Name:MITCHELL CHARONNAT, TERRY (MS)
Entity Type:Individual
Prefix:MS
First Name:TERRY
Middle Name:
Last Name:MITCHELL CHARONNAT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:TERRY
Other - Middle Name:L
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:PO BOX 5538
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-0538
Mailing Address - Country:US
Mailing Address - Phone:510-658-3277
Mailing Address - Fax:877-769-9966
Practice Address - Street 1:744 52ND ST
Practice Address - Street 2:SUITE 4200
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1810
Practice Address - Country:US
Practice Address - Phone:510-658-3277
Practice Address - Fax:877-769-9966
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU 508231H00000X
CAHA 1980237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU000508003Medicaid
ZZZ15159ZOtherMEDICARE (INACTIVE)