Healthcare Provider Details

I. General information

NPI: 1629557319
Provider Name (Legal Business Name): PRISCILLA LUNA-MITCHUM DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 W M.L.K JR BLVD SUITE 300
TAMPA FL
33609
US

IV. Provider business mailing address

21756 STATE ROAD 54 STE 102
LUTZ FL
33549-2905
US

V. Phone/Fax

Practice location:
  • Phone: 813-805-8108
  • Fax:
Mailing address:
  • Phone: 727-475-5540
  • Fax: 844-213-8986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT33894
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: