Basic Information
| Provider Information | |||||||||
| NPI: | 1669525150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | VAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2319 HIGHWAY 145 | ||||||||
| Address2: | |||||||||
| City: | SALTILLO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388669199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628699970 | ||||||||
| FaxNumber: | 6628699980 | ||||||||
| Practice Location | |||||||||
| Address1: | 2319 HIGHWAY 145 | ||||||||
| Address2: | |||||||||
| City: | SALTILLO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388669199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628699970 | ||||||||
| FaxNumber: | 6628699980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT3345 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 03501321 | 05 | MS | MEDICAID | 412157378 | 01 | MS | HEALTHLINK, UHC, TRICARE | OTHER |