Provider Demographics
NPI:1780029389
Name:MITCHELL, DOUGLAS (LMT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 OSTRUM ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1116
Mailing Address - Country:US
Mailing Address - Phone:610-573-1145
Mailing Address - Fax:
Practice Address - Street 1:139 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NAZARETH
Practice Address - State:PA
Practice Address - Zip Code:18064-2016
Practice Address - Country:US
Practice Address - Phone:610-573-1145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATMSG000442225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist