Provider Demographics
NPI:1063019073
Name:MITCHELL, DENISE ANGELA JOAN
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:ANGELA JOAN
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 ROUNDTREE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1639
Mailing Address - Country:US
Mailing Address - Phone:415-328-4884
Mailing Address - Fax:
Practice Address - Street 1:131 ROUNDTREE BLVD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1639
Practice Address - Country:US
Practice Address - Phone:415-328-4884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66791225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist