Provider Demographics
NPI:1669253886
Name:CLERVIL, MITCHNIDA (LCSW)
Entity type:Individual
Prefix:
First Name:MITCHNIDA
Middle Name:
Last Name:CLERVIL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 SW BRIDGEPORT DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-7111
Mailing Address - Country:US
Mailing Address - Phone:772-209-8392
Mailing Address - Fax:
Practice Address - Street 1:5655 CORAL RIDGE DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076-3124
Practice Address - Country:US
Practice Address - Phone:772-209-8392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW232471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical