Provider Demographics
NPI:1184084139
Name:POWERS, MITCHELL RYAN (PSYD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:RYAN
Last Name:POWERS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 E WOODFIELD ROAD
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-5113
Mailing Address - Country:US
Mailing Address - Phone:847-240-2211
Mailing Address - Fax:847-240-2418
Practice Address - Street 1:1701 E WOODFIELD ROAD
Practice Address - Street 2:SUITE 1000
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-5113
Practice Address - Country:US
Practice Address - Phone:847-240-2211
Practice Address - Fax:847-240-2418
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207844Medicare PIN