Provider Demographics
NPI:1700060571
Name:MITCHELL, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:BLAIR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:6735 S OGLESBY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-1315
Mailing Address - Country:US
Mailing Address - Phone:708-841-0347
Mailing Address - Fax:708-260-9396
Practice Address - Street 1:6735 S OGLESBY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-1315
Practice Address - Country:US
Practice Address - Phone:708-841-0347
Practice Address - Fax:708-260-9396
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist