Healthcare Provider Details

I. General information

NPI: 1366989535
Provider Name (Legal Business Name): CAITLIN ASHLEY MACKRELL PTA,LAT,ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2017
Last Update Date: 01/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S MAIN ST
OLD FORGE PA
18518-1541
US

IV. Provider business mailing address

501 S MAIN ST
OLD FORGE PA
18518-1541
US

V. Phone/Fax

Practice location:
  • Phone: 570-457-4099
  • Fax: 570-457-7205
Mailing address:
  • Phone: 570-457-4099
  • Fax: 570-457-7205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTE011301
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRTO00154
License Number StatePA

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: