Healthcare Provider Details

I. General information

NPI: 1982036208
Provider Name (Legal Business Name): VICTORIA MARIE MITCHELL L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2013
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 SANDY BOTTOM RD
COVENTRY RI
02816-5865
US

IV. Provider business mailing address

137 SANDY BOTTOM RD
COVENTRY RI
02816-5865
US

V. Phone/Fax

Practice location:
  • Phone: 401-822-3676
  • Fax:
Mailing address:
  • Phone: 401-588-1524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT01231
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: