Provider Demographics
NPI:1346294394
Name:MITCHELL, MAX HAMILTON (PT)
Entity Type:Individual
Prefix:MR
First Name:MAX
Middle Name:HAMILTON
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3909 NE STALLINGS DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-2169
Mailing Address - Country:US
Mailing Address - Phone:936-564-7780
Mailing Address - Fax:936-564-0745
Practice Address - Street 1:3909 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965
Practice Address - Country:US
Practice Address - Phone:936-564-7780
Practice Address - Fax:936-564-0745
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1065480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX021252401Medicaid
TX1065480OtherTX BOARD OF PT EXAMINERS
TX454509Medicare Oscar/Certification