Basic Information
| Provider Information | |||||||||
| NPI: | 1225373871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | AMI | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8419 | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395358087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2283885714 | ||||||||
| FaxNumber: | 2283880017 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 BEACH DR | ||||||||
| Address2: | PT DEPARTMENT | ||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395071553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288974452 | ||||||||
| FaxNumber: | 2283880017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2012 | ||||||||
| LastUpdateDate: | 03/28/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT2632 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 05638788 | 01 | MS | MEDICAID | OTHER |