Provider Demographics
NPI:1376388744
Name:MAVES, MITCHELL BRIAN
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:BRIAN
Last Name:MAVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 N BELT W
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5612
Mailing Address - Country:US
Mailing Address - Phone:618-622-3717
Mailing Address - Fax:
Practice Address - Street 1:4100 N BELT W
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5612
Practice Address - Country:US
Practice Address - Phone:618-622-3717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024016484237700000X
IL3589237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist