Provider Demographics
NPI:1245350255
Name:MITCHELL, LAURIE E (PT)
Entity type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:E
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:LAURIE
Other - Middle Name:E
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1122 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-6536
Mailing Address - Country:US
Mailing Address - Phone:920-262-2454
Mailing Address - Fax:
Practice Address - Street 1:125 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3303
Practice Address - Country:US
Practice Address - Phone:920-262-4220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4807-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist