Provider Demographics
NPI:1003354242
Name:TAFFE, MITCH (MS, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:MITCH
Middle Name:
Last Name:TAFFE
Suffix:
Gender:M
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 N GRANT ST APT 6B
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-1824
Mailing Address - Country:US
Mailing Address - Phone:320-305-1147
Mailing Address - Fax:
Practice Address - Street 1:1001 E 17TH ST
Practice Address - Street 2:ATHLETIC TRAINING
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-1590
Practice Address - Country:US
Practice Address - Phone:320-305-1147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002707A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
INYRP053M85918OtherBLUECROSS BLUESHIELD