Healthcare Provider Details

I. General information

NPI: 1144201369
Provider Name (Legal Business Name): MITCHELL DEAN HAUSCHILDT MA, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4331 S FREMONT AVE HEALTHTRACKS SPORTS TRAINING CENTER
SPRINGFIELD MO
65804-7328
US

IV. Provider business mailing address

2308 LUNAR ST
REPUBLIC MO
65738-1759
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-5010
  • Fax: 417-820-5022
Mailing address:
  • Phone: 417-732-2843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2002007678
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: