Healthcare Provider Details

I. General information

NPI: 1992198329
Provider Name (Legal Business Name): CAROLYN MICHELLE MITCHELL DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2015
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5831 N NORTHWEST HWY
CHICAGO IL
60631-2642
US

IV. Provider business mailing address

1049 E WILSON ST SUITE 100
BATAVIA IL
60510-2474
US

V. Phone/Fax

Practice location:
  • Phone: 773-775-8080
  • Fax:
Mailing address:
  • Phone: 630-761-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070021293
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: