Healthcare Provider Details

I. General information

NPI: 1831508662
Provider Name (Legal Business Name): MATTHEW BRYANT MITCHELL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BALD HILL RD #511
WARWICK RI
02886
US

IV. Provider business mailing address

125 GOFF AVE APARTMENT 1101
PAWTUCKET RI
02860
US

V. Phone/Fax

Practice location:
  • Phone: 401-738-8100
  • Fax:
Mailing address:
  • Phone: 609-339-6007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT02703
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number21164
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305208771
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: