Provider Demographics
NPI:1063887792
Name:MCKAY, MITCHELL KURT
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:KURT
Last Name:MCKAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S SHAFER ST
Mailing Address - Street 2:2006
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701
Mailing Address - Country:US
Mailing Address - Phone:801-458-4240
Mailing Address - Fax:
Practice Address - Street 1:15 S SHAFER ST
Practice Address - Street 2:2006
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701
Practice Address - Country:US
Practice Address - Phone:801-458-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0047032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer