Provider Demographics
NPI:1659739134
Name:MITCHELL, KENNETH (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MARCELLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13108-1359
Mailing Address - Country:US
Mailing Address - Phone:315-673-1007
Mailing Address - Fax:315-673-2008
Practice Address - Street 1:37 SOUTH ST
Practice Address - Street 2:
Practice Address - City:MARCELLUS
Practice Address - State:NY
Practice Address - Zip Code:13108-1359
Practice Address - Country:US
Practice Address - Phone:315-673-1007
Practice Address - Fax:315-673-2008
Is Sole Proprietor?:No
Enumeration Date:2016-01-29
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026471174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist