Provider Demographics
NPI:1922181015
Name:MITCHELL, JUDY L (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:L
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 E 21ST ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4443
Mailing Address - Country:US
Mailing Address - Phone:505-762-0212
Mailing Address - Fax:505-762-0660
Practice Address - Street 1:921 E 21ST ST
Practice Address - Street 2:SUITE D
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4443
Practice Address - Country:US
Practice Address - Phone:505-762-0212
Practice Address - Fax:505-762-0660
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2577101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM01R63FOtherBLUE CROSS BLUE SHIELD
NM70173737Medicaid