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General NPI Number Information
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NPI Number | 1093967317
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Entity Type | Individual
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Provider Name | BONITA ANN MITCHELL MASSAGE THERAPIST MT
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Gender | Female
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Dates
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Enumeration Date | 10/17/2008
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Last Update Date | 10/17/2008
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Provider Practice Location Address
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Address Line | 235 RUBY DR. CREATIVE MOVEMENT WORKSHOP
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City | MACON
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State | GA
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Zip | 31208
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Country | US
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Telephone | 478-755-8844
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Fax | 478-746-7217
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Provider Business Mailing Address
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Address Line | P.O. BOX 13412 235 RUBY DR. CREATIVE MOVEMENT WORKSHOP
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City | MACON
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State | GA
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Zip | 31208
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Country | US
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Telephone | 478-755-8844
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Fax | 478-746-7217
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT001093
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License Number State | GA
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