Provider Demographics
NPI:1659633527
Name:MITCHELL, REGINALD DARNELL JR (LMT)
Entity type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:DARNELL
Last Name:MITCHELL
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4238 DEVOE AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-4752
Mailing Address - Country:US
Mailing Address - Phone:321-507-8985
Mailing Address - Fax:
Practice Address - Street 1:4238 DEVOE AVE
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-4752
Practice Address - Country:US
Practice Address - Phone:321-507-8985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA68223225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist