Provider Demographics
NPI:1336451913
Name:MITCHELL, REVA D
Entity Type:Individual
Prefix:MRS
First Name:REVA
Middle Name:D
Last Name:MITCHELL
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 1:1406 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-5804
Mailing Address - Country:US
Mailing Address - Phone:810-987-1258
Mailing Address - Fax:810-987-3505
Practice Address - Street 1:1406 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5804
Practice Address - Country:US
Practice Address - Phone:810-987-1258
Practice Address - Fax:810-987-3505
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)