Provider Demographics
NPI:1295503795
Name:MITCH, KRYSTIN
Entity type:Individual
Prefix:
First Name:KRYSTIN
Middle Name:
Last Name:MITCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38351 HAZEL ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-3566
Mailing Address - Country:US
Mailing Address - Phone:586-630-9675
Mailing Address - Fax:
Practice Address - Street 1:38351 HAZEL ST
Practice Address - Street 2:
Practice Address - City:HARRISON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48045-3566
Practice Address - Country:US
Practice Address - Phone:586-630-9675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011041571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical