Provider Demographics
NPI:1629670328
Name:MITCHELL, BRECK ALAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRECK
Middle Name:ALAN
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:
Practice Address - Street 1:501 S MADISON ST STE L
Practice Address - Street 2:
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-2426
Practice Address - Country:US
Practice Address - Phone:417-673-2156
Practice Address - Fax:417-673-2176
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020037945225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2020037945OtherSTATE OF MISSOURI LICENSE