Provider Demographics
NPI:1760951081
Name:MITCHELL, LAUREN (PTA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18755 ROSEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-1092
Mailing Address - Country:US
Mailing Address - Phone:708-826-0081
Mailing Address - Fax:
Practice Address - Street 1:1201 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:BEECHER
Practice Address - State:IL
Practice Address - Zip Code:60401-4040
Practice Address - Country:US
Practice Address - Phone:708-946-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008408225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant