Provider Demographics
NPI:1194235408
Name:MEYER, MITCHELL KORY (AT, ATC)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:KORY
Last Name:MEYER
Suffix:
Gender:M
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9125 YELLOW TREE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5935
Mailing Address - Country:US
Mailing Address - Phone:260-705-7187
Mailing Address - Fax:
Practice Address - Street 1:9125 YELLOW TREE CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-705-7187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 390200000X
OHAT0056452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program