Provider Demographics
NPI:1366632168
Name:LAMM, MITCHELL R
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:R
Last Name:LAMM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 VILLAGE SQUARE DRIVE
Mailing Address - Street 2:STE B
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001
Mailing Address - Country:US
Mailing Address - Phone:270-443-0681
Mailing Address - Fax:
Practice Address - Street 1:5050 VILLAGE SQUARE DRIVE
Practice Address - Street 2:STE B
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001
Practice Address - Country:US
Practice Address - Phone:270-443-0681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02139225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant