Healthcare Provider Details

I. General information

NPI: 1356791917
Provider Name (Legal Business Name): THERESSA L. LABARRIE MITCHELL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W MADISON ST STE 2100
CHICAGO IL
60606-3521
US

IV. Provider business mailing address

200 W MADISON ST STE 2100
CHICAGO IL
60606-3521
US

V. Phone/Fax

Practice location:
  • Phone: 312-522-8280
  • Fax:
Mailing address:
  • Phone: 312-522-8280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.009800
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number071.009800
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: