Provider Demographics
NPI:1083700769
Name:ETCHISON, MONA L (PSYD)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:L
Last Name:ETCHISON
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 1:12255 S 80TH AVENUE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463
Mailing Address - Country:US
Mailing Address - Phone:708-923-7878
Mailing Address - Fax:708-923-7888
Practice Address - Street 1:12255 S 80TH AVENUE
Practice Address - Street 2:SUITE 202
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463
Practice Address - Country:US
Practice Address - Phone:708-923-7878
Practice Address - Fax:708-923-7888
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0991516762OtherBCBS
IL7229POtherCATERPILLAR
IL219043OtherMAGELLAN
IL536182OtherVALUE BEHAVIORAL HEALTH
IL7229POtherCATERPILLAR
ILK27395Medicare ID - Type UnspecifiedDUPAGE COUNTY