Provider Demographics
NPI:1972138659
Name:MITCHELL, SAMANTHA (LCMHC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:FOGLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCMHC
Mailing Address - Street 1:2732 ANN ELIZABETH DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-6650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2732 ANN ELIZABETH DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-6650
Practice Address - Country:US
Practice Address - Phone:336-229-5905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13780101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC47-448805Medicaid