Provider Demographics
NPI:1922455492
Name:BERTRAND, MITCHELL (ATR, ATC)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:BERTRAND
Suffix:
Gender:M
Credentials:ATR, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 AVONDALE DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-5902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2502 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5252
Practice Address - Country:US
Practice Address - Phone:651-231-5573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-15
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27762255A2300X
WI2156-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer