1851925598 NPI number — KELLI SUSAN MITCHELL-WYATT LMSW

Table of content: ELIZABETH LOVELACE (NPI 1508616350)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851925598 NPI number — KELLI SUSAN MITCHELL-WYATT LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHELL-WYATT
Provider First Name:
KELLI
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MITCHELL
Provider Other First Name:
KELLI
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1851925598
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6113 TEN MILE BRIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76135-1335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-585-6710
Provider Business Mailing Address Fax Number:
682-707-5799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6113 TEN MILE BRIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76135-1335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-585-6710
Provider Business Practice Location Address Fax Number:
682-707-5799
Provider Enumeration Date:
03/02/2020

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 , with the licence number:  S26320 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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