Healthcare Provider Details

I. General information

NPI: 1851375273
Provider Name (Legal Business Name): KATHERYN GRACE MITCHELL A.T.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 BABCOCK ST SPORTS MEDICINE
BOSTON MA
02215-1003
US

IV. Provider business mailing address

104 FISHER RUN RD
BLOOMSBURG PA
17815-7431
US

V. Phone/Fax

Practice location:
  • Phone: 617-353-2746
  • Fax: 617-353-7579
Mailing address:
  • Phone: 570-784-1127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1637
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: