Provider Demographics
NPI:1023020658
Name:MITCHELL, VICTORIA L (LCSW)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:L
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 S OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-9078
Mailing Address - Country:US
Mailing Address - Phone:309-263-5565
Mailing Address - Fax:309-263-9336
Practice Address - Street 1:75 E QUEENWOOD RD
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2985
Practice Address - Country:US
Practice Address - Phone:309-263-5565
Practice Address - Fax:309-263-9336
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL87367Medicare ID - Type Unspecified