=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275355265
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN C MITCHELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2024
-----------------------------------------------------
Last Update Date | 10/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 975 MERRIAM AVENUE SUITE 210
-----------------------------------------------------
City | LEOMINSTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-696-6781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 975 MERRIAM AVE STE 210
-----------------------------------------------------
City | LEOMINSTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01453-1240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------