Healthcare Provider Details

I. General information

NPI: 1528923646
Provider Name (Legal Business Name): NICHOLAS MITCHELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7855 CURRIER DR
PORTAGE MI
49002-4314
US

IV. Provider business mailing address

5805 CRANSTON ST
PORTAGE MI
49002-2225
US

V. Phone/Fax

Practice location:
  • Phone: 269-323-7748
  • Fax:
Mailing address:
  • Phone: 517-227-6313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502005591
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: