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General NPI Number Information
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NPI Number | 1265055420
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Entity Type | Individual
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Provider Name | MITCHELL GORDON NIELSEN PTA
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Gender | Male
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Dates
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Enumeration Date | 05/22/2020
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Last Update Date | 05/22/2020
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Provider Practice Location Address
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Address Line | 573 AMBOY AVE
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City | WOODBRIDGE
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State | NJ
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Zip | 07095-3049
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Country | US
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Telephone | 908-282-3737
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Fax |
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Provider Business Mailing Address
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Address Line | 344 HULSE AVE
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City | BRICK
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State | NJ
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Zip | 08724-1516
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Country | US
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Telephone | 412-952-0019
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Fax |
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 40QB00295300
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License Number State | NJ
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