Provider Demographics
NPI:1275774903
Name:MITCHELL, JOSEPH GERARD (LICAC)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:GERARD
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4836 ELM ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-5216
Mailing Address - Country:US
Mailing Address - Phone:847-674-7274
Mailing Address - Fax:
Practice Address - Street 1:4836 ELM ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-5216
Practice Address - Country:US
Practice Address - Phone:847-674-7274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000379171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist