Provider Demographics
NPI:1992243091
Name:POTTLE, MITCHELL (OTR/L)
Entity type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:
Last Name:POTTLE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11530 NE YACHT HARBOR DR
Mailing Address - Street 2:APT#D-211
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3590
Mailing Address - Country:US
Mailing Address - Phone:207-356-9356
Mailing Address - Fax:
Practice Address - Street 1:11530 NE YACHT HARBOR DR
Practice Address - Street 2:APT#D-211
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-3590
Practice Address - Country:US
Practice Address - Phone:207-356-9356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR377857225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist