Provider Demographics
NPI:1174633192
Name:MITZEL NICHOLAS, SHANA D (PSY D)
Entity Type:Individual
Prefix:DR
First Name:SHANA
Middle Name:D
Last Name:MITZEL NICHOLAS
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E ROOSEVELT RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-1908
Mailing Address - Country:US
Mailing Address - Phone:847-732-1704
Mailing Address - Fax:
Practice Address - Street 1:300 E ROOSEVELT RD
Practice Address - Street 2:SUITE 105
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-1908
Practice Address - Country:US
Practice Address - Phone:847-732-1704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006921103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01635721OtherBCBS