Provider Demographics
NPI:1073903126
Name:MITCHELL, STEPHANIE (MMP, CRP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MMP, CRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 BEVERLY BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-4023
Mailing Address - Country:US
Mailing Address - Phone:540-400-4980
Mailing Address - Fax:
Practice Address - Street 1:2105 ELECTRIC RD
Practice Address - Street 2:SUITE 103
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-2315
Practice Address - Country:US
Practice Address - Phone:540-400-0004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019012842225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist