Provider Demographics
NPI:1396010013
Name:MITCHUM, TERRENCE PRESTON
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:PRESTON
Last Name:MITCHUM
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 1:4200 COMMUNITY DR
Mailing Address - Street 2:#804
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-2742
Mailing Address - Country:US
Mailing Address - Phone:561-729-3236
Mailing Address - Fax:
Practice Address - Street 1:4200 COMMUNITY DR
Practice Address - Street 2:#804
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-2742
Practice Address - Country:US
Practice Address - Phone:561-729-3236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 63880225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist