Provider Demographics
NPI:1740997063
Name:MITCHELL, LILLIAN ABAGAIL
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:ABAGAIL
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 1:1037 KINDLY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-4257
Mailing Address - Country:US
Mailing Address - Phone:239-284-6540
Mailing Address - Fax:
Practice Address - Street 1:8359 BEACON BLVD STE 416
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3065
Practice Address - Country:US
Practice Address - Phone:800-920-1927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15757922Medicaid