Provider Demographics
NPI:1972806644
Name:MITCHELL, TIMOTHY W (PT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:W
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 COUNTY ROAD 25
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:OH
Mailing Address - Zip Code:43910-7789
Mailing Address - Country:US
Mailing Address - Phone:740-424-8243
Mailing Address - Fax:
Practice Address - Street 1:2320 COUNTY ROAD 25
Practice Address - Street 2:
Practice Address - City:BLOOMINDALE
Practice Address - State:OH
Practice Address - Zip Code:43910
Practice Address - Country:US
Practice Address - Phone:740-424-8243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-17
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002922225100000X
OH013103225100000X
PAPT021809225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PT002922OtherWV LICENSE
PT013103OtherOHIO LICENSE
OHH009621Medicare PIN
PT013103OtherOHIO LICENSE