Provider Demographics
NPI:1942849120
Name:MITCHELL, GARY (LMT, CPT)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:LMT, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-2235
Mailing Address - Country:US
Mailing Address - Phone:651-208-6551
Mailing Address - Fax:
Practice Address - Street 1:504 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-2235
Practice Address - Country:US
Practice Address - Phone:651-208-6551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-05
Last Update Date:2020-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10478-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist