Basic Information
| Provider Information | |||||||||
| NPI: | 1922340512 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | HUNTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 SHIPYARD BLVD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284126431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103430145 | ||||||||
| FaxNumber: | 9102029966 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 SHIPYARD BLVD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107900187 | ||||||||
| FaxNumber: | 9107900189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2013 | ||||||||
| LastUpdateDate: | 07/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCAS 21242 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | C010351 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.