Provider Demographics
NPI:1922213974
Name:MITCHELL, MICHELLE D (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:D
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 725575
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31139-2575
Mailing Address - Country:US
Mailing Address - Phone:404-516-1996
Mailing Address - Fax:678-309-3730
Practice Address - Street 1:3480 GREENBRIAR PKWY SW STE 230
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-3123
Practice Address - Country:US
Practice Address - Phone:404-516-1996
Practice Address - Fax:678-309-3730
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002833103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10044615OtherAMERIGROUP PRACTITIONER #