Provider Demographics
NPI:1649002668
Name:PREVATTE, MITCHELL REED
Entity type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:REED
Last Name:PREVATTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 GRANVILLE DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-5708
Mailing Address - Country:US
Mailing Address - Phone:336-442-6461
Mailing Address - Fax:
Practice Address - Street 1:936 W 4TH ST STE 204
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2564
Practice Address - Country:US
Practice Address - Phone:336-442-6461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20442101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health