Provider Demographics
NPI:1912219890
Name:MITO, MARION JACKSON (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:JACKSON
Last Name:MITO
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2616 N WILSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-2275
Mailing Address - Country:US
Mailing Address - Phone:847-253-2278
Mailing Address - Fax:847-253-2278
Practice Address - Street 1:1875 DEMPSTER ST
Practice Address - Street 2:PARKSIDE G-10
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1186
Practice Address - Country:US
Practice Address - Phone:847-723-7848
Practice Address - Fax:847-723-2223
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.001757235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist