Provider Demographics
NPI:1053387258
Name:ROBERT C. MITCHELL
Entity type:Organization
Organization Name:ROBERT C. MITCHELL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER-DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:618-988-1757
Mailing Address - Street 1:1220 S PARK AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-4177
Mailing Address - Country:US
Mailing Address - Phone:618-988-1757
Mailing Address - Fax:618-988-1700
Practice Address - Street 1:1220 S PARK AVE
Practice Address - Street 2:SUITE D
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-4177
Practice Address - Country:US
Practice Address - Phone:618-988-1757
Practice Address - Fax:618-988-1700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIGO10320OtherMAGELLAN
IL1618888OtherBLUE CROSS/BLUE SHIELD
IL5919746OtherAETNA EAP
IL957562Medicare ID - Type UnspecifiedMEDICARE