Provider Demographics
NPI:1932553591
Name:MITCHELL, TIEQUENCCIA
Entity Type:Individual
Prefix:
First Name:TIEQUENCCIA
Middle Name:
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 1:880 S PLEASANTBURG DR
Mailing Address - Street 2:SUITE 2E OFFICE A
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-2422
Mailing Address - Country:US
Mailing Address - Phone:864-551-4244
Mailing Address - Fax:864-370-7200
Practice Address - Street 1:25 WOODS LAKE RD STE 506
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2767
Practice Address - Country:US
Practice Address - Phone:864-552-1496
Practice Address - Fax:864-370-7200
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-0345251E00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCEX1476Medicaid
SCIHCP-0345OtherDHEC