Provider Demographics
NPI:1821429515
Name:NEATHERY, MIMI (PSYD)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:
Last Name:NEATHERY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 N DEARBORN ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3873
Mailing Address - Country:US
Mailing Address - Phone:773-580-9121
Mailing Address - Fax:312-291-9723
Practice Address - Street 1:650 N DEARBORN ST
Practice Address - Street 2:SUITE 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3873
Practice Address - Country:US
Practice Address - Phone:773-580-9121
Practice Address - Fax:312-291-9723
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008698103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical