Provider Demographics
NPI:1679717706
Name:MENDENHALL, CHRISTINE MICHELLE (PSYD,LCPC,CADC,MISA)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:MICHELLE
Last Name:MENDENHALL
Suffix:
Gender:F
Credentials:PSYD,LCPC,CADC,MISA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14127 LEAVITT AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-3242
Mailing Address - Country:US
Mailing Address - Phone:708-275-5824
Mailing Address - Fax:
Practice Address - Street 1:14127 LEAVITT AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-3242
Practice Address - Country:US
Practice Address - Phone:708-275-5824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL21415101YA0400X
IL180.007149101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid