Provider Demographics
NPI:1295705424
Name:MITCHELL, MATTHEW D (OT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 US HIGHWAY 224
Mailing Address - Street 2:
Mailing Address - City:NOVA
Mailing Address - State:OH
Mailing Address - Zip Code:44859-9770
Mailing Address - Country:US
Mailing Address - Phone:419-652-2219
Mailing Address - Fax:419-652-2219
Practice Address - Street 1:1069 US HIGHWAY 224
Practice Address - Street 2:
Practice Address - City:NOVA
Practice Address - State:OH
Practice Address - Zip Code:44859-9770
Practice Address - Country:US
Practice Address - Phone:419-652-2219
Practice Address - Fax:419-652-2219
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT004389225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000325537OtherANTHEM BLUE CROSS