Healthcare Provider Details

I. General information

NPI: 1588790455
Provider Name (Legal Business Name): MAUREEN MITCHELL LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 03/17/2024
Certification Date: 03/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4049 GARY DR
NORTH CHARLESTON SC
29405-8617
US

IV. Provider business mailing address

4049 GARY DR
NORTH CHARLESTON SC
29405-8617
US

V. Phone/Fax

Practice location:
  • Phone: 360-789-3836
  • Fax:
Mailing address:
  • Phone: 360-789-3836
  • Fax: 360-400-1553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number11267
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: