Provider Demographics
NPI:1164481958
Name:SMELIS, MITCHELL JASON (ATC)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:JASON
Last Name:SMELIS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 W SILVER LAKE RD
Mailing Address - Street 2:PHYSIOTHERAPY ASSOCIATES
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1374
Mailing Address - Country:US
Mailing Address - Phone:810-714-4616
Mailing Address - Fax:
Practice Address - Street 1:3200 W SHIAWASSEE AVE
Practice Address - Street 2:FENTON HIGH SCHOOL ATHLETICS
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-1762
Practice Address - Country:US
Practice Address - Phone:810-591-2629
Practice Address - Fax:810-591-2624
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2012-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010004152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer