Provider Demographics
NPI:1588192793
Name:MCTIER, MITCHELL
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:MCTIER
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 1:113 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-5591
Mailing Address - Country:US
Mailing Address - Phone:770-337-3607
Mailing Address - Fax:770-337-3607
Practice Address - Street 1:1106 S BLAKE AVE
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-4117
Practice Address - Country:US
Practice Address - Phone:208-885-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA878507380OtherUNITED HEALTHCARE