Provider Demographics
NPI:1801342761
Name:MITCHELL, GREGORY LEWIS (PTA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:LEWIS
Last Name:MITCHELL
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 1:1001 ESTATE ROSS SUITE 6, BARBEL PLAZA
Mailing Address - Street 2:
Mailing Address - City:SAINT THOMAS
Mailing Address - State:VI
Mailing Address - Zip Code:00802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 ESTATE ROSS SUITE 6, BARBEL PLAZA
Practice Address - Street 2:
Practice Address - City:SAINT THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802
Practice Address - Country:US
Practice Address - Phone:340-779-4678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006591225200000X
PATEI004510225200000X
VI001225200000X
TX2118853225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant