Provider Demographics
NPI:1093775322
Name:MITCHELL, JUSTIN DOUGLAS (PT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DOUGLAS
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1393 CELANESE RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1722
Mailing Address - Country:US
Mailing Address - Phone:803-329-3103
Mailing Address - Fax:803-325-2232
Practice Address - Street 1:1393 CELANESE RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1722
Practice Address - Country:US
Practice Address - Phone:803-329-3103
Practice Address - Fax:803-325-2232
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3834225100000X
NC6620225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
E1570OtherMEDCOST
NC0788COtherBLUE CROSS BLUE SHIELD NC