Provider Demographics
NPI:1811146749
Name:MITCHELL, KELLY MARIE
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1970
Mailing Address - Street 2:
Mailing Address - City:BELCOURT
Mailing Address - State:ND
Mailing Address - Zip Code:58316-1970
Mailing Address - Country:US
Mailing Address - Phone:701-477-0525
Mailing Address - Fax:701-477-0527
Practice Address - Street 1:BIA ROAD # 7 BUILDING #152
Practice Address - Street 2:
Practice Address - City:BELCOURT
Practice Address - State:ND
Practice Address - Zip Code:58316-1970
Practice Address - Country:US
Practice Address - Phone:701-477-0525
Practice Address - Fax:701-477-0527
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker