Provider Demographics
NPI:1871331090
Name:MITCHELL, SHANE SR
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:MITCHELL
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N ESTELLE AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4616
Mailing Address - Country:US
Mailing Address - Phone:316-619-9435
Mailing Address - Fax:
Practice Address - Street 1:225 N ESTELLE AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4616
Practice Address - Country:US
Practice Address - Phone:316-619-9435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-20
Last Update Date:2024-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty