Healthcare Provider Details

I. General information

NPI: 1770081812
Provider Name (Legal Business Name): MR. MITCHELL GREGORY SKINNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 FOOTHILL BLVD
LA CANADA FLINTRIDGE CA
91011-3503
US

IV. Provider business mailing address

5017 LA CRESCENTA AVE
LA CRESCENTA CA
91214-2116
US

V. Phone/Fax

Practice location:
  • Phone: 818-369-7620
  • Fax: 818-369-7621
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number308739
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: