Provider Demographics
NPI:1114968195
Name:MITCHELL, ANDREA GRACE SR (MSPT)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:GRACE
Last Name:MITCHELL
Suffix:SR
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 LOWDEN ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-6045
Mailing Address - Country:US
Mailing Address - Phone:401-439-1668
Mailing Address - Fax:
Practice Address - Street 1:45 SEEKONK ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-5125
Practice Address - Country:US
Practice Address - Phone:401-230-1126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01666225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI27943-1OtherBCBS
RI411986OtherBCHIP