Provider Demographics
NPI:1265071021
Name:NESTLER, MITCHELL DECLAN (PTA)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DECLAN
Last Name:NESTLER
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 1:18 PROFESSIONAL VILLAGE CIR
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29907-1570
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 PROFESSIONAL VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29907-1570
Practice Address - Country:US
Practice Address - Phone:843-986-9670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-27
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4021225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant