Provider Demographics
NPI:1467514927
Name:MITCHELL, KENNETH WAYNE (OTR)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3475 BRENT DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35243-1607
Mailing Address - Country:US
Mailing Address - Phone:205-862-6465
Mailing Address - Fax:205-967-0537
Practice Address - Street 1:3475 BRENT DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35243-1607
Practice Address - Country:US
Practice Address - Phone:205-862-6465
Practice Address - Fax:205-967-0537
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1022225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist