Provider Demographics
NPI:1851128375
Name:MITTELBRUN, GRACE KATHERINE (LSW)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:KATHERINE
Last Name:MITTELBRUN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 W MARION ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-1747
Mailing Address - Country:US
Mailing Address - Phone:217-308-8040
Mailing Address - Fax:
Practice Address - Street 1:100 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:ATWOOD
Practice Address - State:IL
Practice Address - Zip Code:61913-7233
Practice Address - Country:US
Practice Address - Phone:217-578-3814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.114336104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker