Provider Demographics
NPI:1922659705
Name:MITCHELL, GINA ALEXANDRA (LSW)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:ALEXANDRA
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WALNUT ST STE 300
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3643
Mailing Address - Country:US
Mailing Address - Phone:215-563-7863
Mailing Address - Fax:
Practice Address - Street 1:500 WALNUT ST STE 300
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-3643
Practice Address - Country:US
Practice Address - Phone:215-563-7863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW135638104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME6094324OtherDRIVER'S LICENSE