Provider Demographics
NPI:1790374445
Name:MITZEL, TAYLOR L
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:L
Last Name:MITZEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3275 W HALEY DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-3370
Mailing Address - Country:US
Mailing Address - Phone:831-801-4047
Mailing Address - Fax:
Practice Address - Street 1:2127 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3149
Practice Address - Country:US
Practice Address - Phone:208-321-4898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-2051224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant