Basic Information
| Provider Information | |||||||||
| NPI: | 1144729898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAVIN | ||||||||
| FirstName: | MITZI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1819 HENDRICKS AVE STE 2AND3 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322073303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043485511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1819 HENDRICKS AVE STE 2AND3 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322073303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043485511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2018 | ||||||||
| LastUpdateDate: | 02/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT4805 | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | NA | 01 | FL | NA | OTHER |