Provider Demographics
NPI:1265055420
Name:NIELSEN, MITCHELL GORDON (PTA)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:GORDON
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 HULSE AVE
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-1516
Mailing Address - Country:US
Mailing Address - Phone:412-952-0019
Mailing Address - Fax:
Practice Address - Street 1:573 AMBOY AVE
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095-3049
Practice Address - Country:US
Practice Address - Phone:908-282-3737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00295300225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant