Provider Demographics
NPI:1447961305
Name:MITCH, NICOLE (LMT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MITCH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W 122ND ST # 42
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-5363
Mailing Address - Country:US
Mailing Address - Phone:124-642-2345
Mailing Address - Fax:
Practice Address - Street 1:300 W 122ND ST # 42
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-5363
Practice Address - Country:US
Practice Address - Phone:648-269-4451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031768-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist