Provider Demographics
NPI:1114514999
Name:MITCHELL, STACEY (DPT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:AUSTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:2 E MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5844
Practice Address - Country:US
Practice Address - Phone:217-709-9000
Practice Address - Fax:217-709-9001
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017140225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist