Provider Demographics
NPI:1366989535
Name:MACKRELL, CAITLIN ASHLEY (PTA,LAT,ATC)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:ASHLEY
Last Name:MACKRELL
Suffix:
Gender:F
Credentials:PTA,LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1541
Mailing Address - Country:US
Mailing Address - Phone:570-457-4099
Mailing Address - Fax:570-457-7205
Practice Address - Street 1:501 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-1541
Practice Address - Country:US
Practice Address - Phone:570-457-4099
Practice Address - Fax:570-457-7205
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE011301225200000X
PARTO001542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer