Provider Demographics
NPI:1770081812
Name:SKINNER, MITCHELL GREGORY
Entity type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:GREGORY
Last Name:SKINNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5017 LA CRESCENTA AVE
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-2116
Mailing Address - Country:US
Mailing Address - Phone:818-437-0745
Mailing Address - Fax:
Practice Address - Street 1:5017 LA CRESCENTA AVE
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-2116
Practice Address - Country:US
Practice Address - Phone:818-437-0745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer