MEDICARE: MYIA MITCHELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	7296-085	WI

General Provider Information

NPI Number	:	1164807889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYIA MITCHELL

Provider Business Mailing Address
First Line	:	PO BOX 100144
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-0144
Country	:	US
Telephone Number	:	414-807-9555
Fax Number	:

Provider Business Practice Location Address
First Line	:	6012 W. NORTH AVENUE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53213
Country	:	US
Telephone Number	:	414-807-9555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2015
Last Update Date	:	07/23/2015

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Directions to “ MYIA MITCHELL ” Practice Location

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