Provider Demographics
NPI:1558765461
Name:MITCHELL, SAMANTHA (LATC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:READFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04355
Mailing Address - Country:US
Mailing Address - Phone:207-215-6982
Mailing Address - Fax:
Practice Address - Street 1:1113 MAIN ST
Practice Address - Street 2:
Practice Address - City:READFIELD
Practice Address - State:ME
Practice Address - Zip Code:04355
Practice Address - Country:US
Practice Address - Phone:207-215-6982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT5342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer