Provider Demographics
NPI:1629660535
Name:MITCHELL, RYAN (PTA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5825 MILL ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3363
Mailing Address - Country:US
Mailing Address - Phone:810-282-1345
Mailing Address - Fax:
Practice Address - Street 1:3058 N STATE RD STE E
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-3508
Practice Address - Country:US
Practice Address - Phone:810-652-6315
Practice Address - Fax:810-652-6213
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI120892255A2300X
MI5502005419225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer