Provider Demographics
NPI:1053460634
Name:MITCHELL, KIRSTEN L (PSYD)
Entity Type:Individual
Prefix:MRS
First Name:KIRSTEN
Middle Name:L
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2081 CALISTOGA DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-4831
Mailing Address - Country:US
Mailing Address - Phone:815-277-9906
Mailing Address - Fax:815-277-9907
Practice Address - Street 1:2081 CALISTOGA DR STE 3N
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-4834
Practice Address - Country:US
Practice Address - Phone:815-277-9906
Practice Address - Fax:815-277-9907
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007177103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical