Provider Demographics
NPI:1336430529
Name:MITCHELL, COLLEEN M (OTA)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:M
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:MRS
Other - First Name:COLLEEN
Other - Middle Name:M
Other - Last Name:REQULA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTA
Mailing Address - Street 1:3374 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:12545-5969
Mailing Address - Country:US
Mailing Address - Phone:845-677-6196
Mailing Address - Fax:
Practice Address - Street 1:3374 FRANKLIN AVENUE
Practice Address - Street 2:
Practice Address - City:MILLBROOK
Practice Address - State:NY
Practice Address - Zip Code:12545-5969
Practice Address - Country:US
Practice Address - Phone:845-677-3251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001276-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant