Provider Demographics
NPI:1184836520
Name:MITCHELL, MICA A (MPT)
Entity Type:Individual
Prefix:MRS
First Name:MICA
Middle Name:A
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1507
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28302-1507
Mailing Address - Country:US
Mailing Address - Phone:910-584-9471
Mailing Address - Fax:910-487-3541
Practice Address - Street 1:6536 BURNSIDE PL
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-2907
Practice Address - Country:US
Practice Address - Phone:910-583-9471
Practice Address - Fax:910-487-3541
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9546225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212783Medicaid