Provider Demographics
NPI:1295859577
Name:CHURCHEY-MIMS, MICHELLE ELIZABETH (MA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ELIZABETH
Last Name:CHURCHEY-MIMS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-1717
Mailing Address - Country:US
Mailing Address - Phone:708-385-2079
Mailing Address - Fax:312-829-0710
Practice Address - Street 1:13136 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2423
Practice Address - Country:US
Practice Address - Phone:708-974-5856
Practice Address - Fax:312-829-0710
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional