Provider Demographics
NPI:1356894984
Name:MITCHELL, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:484 MAIN ST
Mailing Address - Street 2:460
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1893
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:484 MAIN ST
Practice Address - Street 2:460
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1893
Practice Address - Country:US
Practice Address - Phone:508-796-1411
Practice Address - Fax:508-796-1455
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2286190101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor