Provider Demographics
NPI:1114271194
Name:MITCHELL, LAUREN E
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:E
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 1:1662 SE GOUCHO AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4944
Mailing Address - Country:US
Mailing Address - Phone:803-316-2082
Mailing Address - Fax:772-299-7868
Practice Address - Street 1:2965 20TH STREET
Practice Address - Street 2:ADVANCED MOTION THERAPEUTIC MASSAGE, INC.
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3097
Practice Address - Country:US
Practice Address - Phone:772-567-8585
Practice Address - Fax:772-299-7868
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22843225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant