Provider Demographics
NPI:1871949016
Name:MITCHELL, CORMICK (MAED)
Entity type:Individual
Prefix:
First Name:CORMICK
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:MAED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 KALISTE SALOOM RD
Mailing Address - Street 2:SUITE 117
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4230
Mailing Address - Country:US
Mailing Address - Phone:337-234-7109
Mailing Address - Fax:337-234-7898
Practice Address - Street 1:850 KALISTE SALOOM RD
Practice Address - Street 2:SUITE 117
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508
Practice Address - Country:US
Practice Address - Phone:337-234-7109
Practice Address - Fax:337-234-7898
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1467745000OtherNPI