Provider Demographics
NPI:1952318446
Name:MITCHELL, MAVERNIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MAVERNIE
Middle Name:
Last Name:MITCHELL
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:PO BOX 5109
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92517-5109
Mailing Address - Country:US
Mailing Address - Phone:951-341-8930
Mailing Address - Fax:951-341-8932
Practice Address - Street 1:4960 ARLINGTON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-2738
Practice Address - Country:US
Practice Address - Phone:951-341-8930
Practice Address - Fax:951-341-8932
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18030101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18030OtherSTATE LICENSE
CAP23539Medicare UPIN
CA18030OtherSTATE LICENSE