Provider Demographics
NPI:1760051783
Name:MITCHELL, MEGUMI IKEDA (MS, ATC/LAT)
Entity Type:Individual
Prefix:
First Name:MEGUMI
Middle Name:IKEDA
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MS, ATC/LAT
Other - Prefix:
Other - First Name:MEGUMI
Other - Middle Name:
Other - Last Name:IKEDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, ATC/LAT
Mailing Address - Street 1:14658 SILVER OAKS LOOP
Mailing Address - Street 2:
Mailing Address - City:SILVERHILL
Mailing Address - State:AL
Mailing Address - Zip Code:36576-3741
Mailing Address - Country:US
Mailing Address - Phone:251-600-9448
Mailing Address - Fax:
Practice Address - Street 1:21630 STATE HIGHWAY 59 S
Practice Address - Street 2:
Practice Address - City:ROBERTSDALE
Practice Address - State:AL
Practice Address - Zip Code:36567-6710
Practice Address - Country:US
Practice Address - Phone:251-947-4154
Practice Address - Fax:251-947-2666
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer