Provider Demographics
NPI:1992157499
Name:MCCANN, MITCHELL (ATC, LAT, CES)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:MCCANN
Suffix:
Gender:M
Credentials:ATC, LAT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 MAPLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7113
Mailing Address - Country:US
Mailing Address - Phone:770-238-9821
Mailing Address - Fax:
Practice Address - Street 1:1 SELIG CIR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30602-1501
Practice Address - Country:US
Practice Address - Phone:706-542-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT10401253-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program