Provider Demographics
NPI:1548717085
Name:HOLDERNESS, MITCHELL EDWARD (DPT)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:EDWARD
Last Name:HOLDERNESS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 LEXINGTON GREEN LN
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1013
Mailing Address - Country:US
Mailing Address - Phone:407-688-0070
Mailing Address - Fax:
Practice Address - Street 1:13335 W HILLSBOROUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33635-9676
Practice Address - Country:US
Practice Address - Phone:813-543-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT31927225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686675Medicare PIN