Provider Demographics
NPI:1437698990
Name:ACHILLE, MITZI
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:
Last Name:ACHILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MITZI
Other - Middle Name:
Other - Last Name:ACHILLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CERTIFIED HAIR LOSS
Mailing Address - Street 1:18122 MARTIN AVE
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2120
Mailing Address - Country:US
Mailing Address - Phone:708-798-4471
Mailing Address - Fax:
Practice Address - Street 1:18122 MARTIN AVE
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2120
Practice Address - Country:US
Practice Address - Phone:708-798-4471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0112432051744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management