1548556293 NPI number — DR. COLLEEN A. MITCHELL PSY

Table of content: DR. COLLEEN A. MITCHELL PSY (NPI 1548556293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548556293 NPI number — DR. COLLEEN A. MITCHELL PSY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHELL
Provider First Name:
COLLEEN
Provider Middle Name:
A.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MITCHELL
Provider Other First Name:
COLLEEN
Provider Other Middle Name:
A.
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSYCHOLOGIST
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1548556293
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
704 KATIE COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-423-1100
Provider Business Mailing Address Fax Number:
608-423-9851

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
704 KATIE COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-423-1100
Provider Business Practice Location Address Fax Number:
608-423-9851
Provider Enumeration Date:
06/21/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  071-008414 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)