Provider Demographics
NPI:1255829081
Name:MITCHELL, JOSEPH MATTHEW (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:MATTHEW
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-4780
Mailing Address - Country:US
Mailing Address - Phone:773-891-6135
Mailing Address - Fax:
Practice Address - Street 1:2103 E WASHINGTON ST STE 1D
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4310
Practice Address - Country:US
Practice Address - Phone:773-245-6704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017411103T00000X
IL071.010644103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist