Basic Information
Provider Information | |||||||||
NPI: | 1801134580 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MITCHELL | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: | WILLIAM | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.T. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1115 BOULDERS PKWY STE 200 | ||||||||
Address2: |   | ||||||||
City: | NORTH CHESTERFIELD | ||||||||
State: | VA | ||||||||
PostalCode: | 232254067 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8045605595 | ||||||||
FaxNumber: | 8045609029 | ||||||||
Practice Location | |||||||||
Address1: | 1849 OLD DONATION PKWY | ||||||||
Address2: |   | ||||||||
City: | VIRGINIA BEACH | ||||||||
State: | VA | ||||||||
PostalCode: | 23454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7574228476 | ||||||||
FaxNumber: | 7574258476 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2013 | ||||||||
LastUpdateDate: | 01/04/2019 | ||||||||
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 | 28860 | FL | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | 2305202408 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.