Provider Demographics
NPI:1780242347
Name:MITCHELL, TYEISHA NICOLE
Entity type:Individual
Prefix:
First Name:TYEISHA
Middle Name:NICOLE
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 1:1 E CHASE ST STE 1105
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2564
Mailing Address - Country:US
Mailing Address - Phone:443-531-1999
Mailing Address - Fax:
Practice Address - Street 1:1 E CHASE ST STE 1105
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2564
Practice Address - Country:US
Practice Address - Phone:443-531-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24830104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD38-3876389Medicaid