1508497017 NPI number — MRS. ERICA DANESE MITCHELL LCSW

Table of content: MRS. ERICA DANESE MITCHELL LCSW (NPI 1508497017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508497017 NPI number — MRS. ERICA DANESE MITCHELL LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHELL
Provider First Name:
ERICA
Provider Middle Name:
DANESE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DANESE
Provider Other First Name:
ERICA
Provider Other Middle Name:
ELAINE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508497017
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8540 BAYCENTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-7420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-394-5703
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8540 BAYCENTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32256-7420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-448-1933
Provider Business Practice Location Address Fax Number:
904-448-0349
Provider Enumeration Date:
02/03/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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