Provider Demographics
NPI:1851375273
Name:MITCHELL, KATHERYN GRACE (ATC)
Entity Type:Individual
Prefix:
First Name:KATHERYN
Middle Name:GRACE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 FISHER RUN RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-7431
Mailing Address - Country:US
Mailing Address - Phone:570-784-1127
Mailing Address - Fax:
Practice Address - Street 1:285 BABCOCK ST
Practice Address - Street 2:SPORTS MEDICINE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1003
Practice Address - Country:US
Practice Address - Phone:617-353-2746
Practice Address - Fax:617-353-7579
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer