Basic Information
| Provider Information | |||||||||
| NPI: | 1083862783 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | SERENITY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | IMF | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2535 KETTNER BLVD | ||||||||
| Address2: | SUITE 1A4 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921011250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196150701 | ||||||||
| FaxNumber: | 6196150705 | ||||||||
| Practice Location | |||||||||
| Address1: | 2535 KETTNER BLVD | ||||||||
| Address2: | SUITE 1A4 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921011250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196150701 | ||||||||
| FaxNumber: | 6196150705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2008 | ||||||||
| LastUpdateDate: | 03/08/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF58512 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.