Provider Demographics
NPI:1720267917
Name:MITCHELL, MARK (LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E LAHARPE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4520
Mailing Address - Country:US
Mailing Address - Phone:660-665-1962
Mailing Address - Fax:660-665-3989
Practice Address - Street 1:2945 S BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2713
Practice Address - Country:US
Practice Address - Phone:314-961-6017
Practice Address - Fax:314-961-6436
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004024006101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional