1720334758 NPI number — MS. SARA IRENE MITCHINSON M.A.,CCC-SLP/L

Table of content: MS. SARA IRENE MITCHINSON M.A.,CCC-SLP/L (NPI 1720334758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720334758 NPI number — MS. SARA IRENE MITCHINSON M.A.,CCC-SLP/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHINSON
Provider First Name:
SARA
Provider Middle Name:
IRENE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.A.,CCC-SLP/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720334758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
516 SARATOGA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELBURN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60119-8338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-365-3548
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 COVENTRY LN STE 170
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRYSTAL LAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60014-7592
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-356-2700
Provider Business Practice Location Address Fax Number:
815-356-2709
Provider Enumeration Date:
07/27/2012

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: 235Z00000X , with the licence number:  146.004614 , 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)





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