Provider Demographics
NPI:1639519358
Name:MITCHELL, MATTHEW WALLACE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WALLACE
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 WATER ST
Mailing Address - Street 2:SUITE 339
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-6706
Mailing Address - Country:US
Mailing Address - Phone:360-441-0142
Mailing Address - Fax:
Practice Address - Street 1:91 W VALLEY RD
Practice Address - Street 2:
Practice Address - City:CHIMACUM
Practice Address - State:WA
Practice Address - Zip Code:98325-7731
Practice Address - Country:US
Practice Address - Phone:360-732-4090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00004327225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist