Provider Demographics
NPI:1821357898
Name:MIX, MORGAN GABRIELLE (MS, BCABA)
Entity Type:Individual
Prefix:MS
First Name:MORGAN
Middle Name:GABRIELLE
Last Name:MIX
Suffix:
Gender:F
Credentials:MS, BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 N MICHIGAN AVE
Mailing Address - Street 2:1909
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7506
Mailing Address - Country:US
Mailing Address - Phone:312-835-0635
Mailing Address - Fax:
Practice Address - Street 1:151 N MICHIGAN AVE
Practice Address - Street 2:1909
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7506
Practice Address - Country:US
Practice Address - Phone:312-835-0635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL67098854103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst