Provider Demographics
NPI:1487950689
Name:MITCHELL, WAYNE JOSEPH JR (OTA)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:JOSEPH
Last Name:MITCHELL
Suffix:JR
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:
Mailing Address - City:GLASCO
Mailing Address - State:NY
Mailing Address - Zip Code:12432-0528
Mailing Address - Country:US
Mailing Address - Phone:845-532-4483
Mailing Address - Fax:
Practice Address - Street 1:268 W SAUGERTIES RD
Practice Address - Street 2:
Practice Address - City:SAUGERTIES
Practice Address - State:NY
Practice Address - Zip Code:12477-3142
Practice Address - Country:US
Practice Address - Phone:845-247-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-04
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007390-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant