Provider Demographics
NPI:1952464380
Name:MITCHELL, RYAN (OT)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82750
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-9441
Mailing Address - Country:US
Mailing Address - Phone:770-722-1347
Mailing Address - Fax:770-761-9755
Practice Address - Street 1:2556 GLENDALE CT NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-1455
Practice Address - Country:US
Practice Address - Phone:770-722-1347
Practice Address - Fax:770-761-9755
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003400225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52873411001OtherBC BS OF GEORGIA