Provider Demographics
NPI:1881051878
Name:MITCHELL, EDEN (CAC)
Entity type:Individual
Prefix:
First Name:EDEN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 E BROOKSTOWN DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70805-4603
Mailing Address - Country:US
Mailing Address - Phone:225-927-0770
Mailing Address - Fax:
Practice Address - Street 1:4255 E BROOKSTOWN DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-4603
Practice Address - Country:US
Practice Address - Phone:225-927-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1354101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA72-1476680Medicaid