Provider Demographics
NPI:1942431176
Name:MITCHELL, KELVIN L (LCSW-C)
Entity type:Individual
Prefix:
First Name:KELVIN
Middle Name:L
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11205 WESTPORT DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-3411
Mailing Address - Country:US
Mailing Address - Phone:301-821-7716
Mailing Address - Fax:301-352-0405
Practice Address - Street 1:12150 ANNAPOLIS RD STE 104
Practice Address - Street 2:
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9183
Practice Address - Country:US
Practice Address - Phone:301-821-7716
Practice Address - Fax:301-352-0405
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500788021041C0700X, 251S00000X
MD152941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD024330200Medicaid
MD024330200Medicaid