Basic Information
Provider Information | |||||||||
NPI: | 1053922583 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ORR | ||||||||
FirstName: | MITCHELL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2082 E 900 S | ||||||||
Address2: |   | ||||||||
City: | SLC | ||||||||
State: | UT | ||||||||
PostalCode: | 841081302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1050 E SOUTH TEMPLE | ||||||||
Address2: |   | ||||||||
City: | SLC | ||||||||
State: | UT | ||||||||
PostalCode: | 841021507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013504111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2020 | ||||||||
LastUpdateDate: | 12/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11868623-2401 | UT | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 208100000X | 11868623-8016 | UT | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
No ID Information.