Provider Demographics
NPI:1043224926
Name:MIRELL, HOLLY N (PHD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:N
Last Name:MIRELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:1818 E. WINDSOR ROAD
Practice Address - Street 2:PSYCHIATRY/PSYCHOLOGY
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61802
Practice Address - Country:US
Practice Address - Phone:217-255-9700
Practice Address - Fax:217-255-9650
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003869103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6447860036Medicare NSC
S31885Medicare UPIN
ILS31885Medicare UPIN
ILIL3270448Medicare PIN