Healthcare Provider Details

I. General information

NPI: 1952704637
Provider Name (Legal Business Name): MITCHELL ANDERSON OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2014
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 UNIVERSITY BLVD NE
ALBUQUERQUE NM
87102-1708
US

IV. Provider business mailing address

1509 UNIVERSITY BLVD NE
ALBUQUERQUE NM
87102-1708
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-4656
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1623
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: