Provider Demographics
NPI:1427424621
Name:MITCHELL, WILLIE PATRICK (PTA, COTA)
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:PATRICK
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:PTA, COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 KERNERSVILLE MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7159
Mailing Address - Country:US
Mailing Address - Phone:336-515-5000
Mailing Address - Fax:
Practice Address - Street 1:1695 KERNERSVILLE MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7159
Practice Address - Country:US
Practice Address - Phone:336-515-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA3460225200000X, 171000000X
NC5978171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider