Provider Demographics
NPI:1922448885
Name:COHEN, MITCHELL R (SAC-IT, PCTL)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:R
Last Name:COHEN
Suffix:
Gender:M
Credentials:SAC-IT, PCTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W. SILVER SPRING RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4300
Mailing Address - Country:US
Mailing Address - Phone:414-847-6253
Mailing Address - Fax:414-501-2361
Practice Address - Street 1:500 W SILVER SPRING DR
Practice Address - Street 2:SUITE 200
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-5051
Practice Address - Country:US
Practice Address - Phone:414-847-6253
Practice Address - Fax:414-501-2361
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16612-130101YA0400X
WI1858-226101YM0800X
101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral