Healthcare Provider Details

I. General information

NPI: 1659765394
Provider Name (Legal Business Name): MITCHELL LAWSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 NE SAINT LUKES BLVD STE 200
LEES SUMMIT MO
64086-6011
US

IV. Provider business mailing address

200 SW 21ST RD
WARRENSBURG MO
64093-7560
US

V. Phone/Fax

Practice location:
  • Phone: 816-246-4302
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2017026436
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: