Healthcare Provider Details

I. General information

NPI: 1679998371
Provider Name (Legal Business Name): BRITTANY MITACEK ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18500 BURNHAM AVE
LANSING IL
60438-3046
US

IV. Provider business mailing address

8629 MANOR AVE APT D
MUNSTER IN
46321-2215
US

V. Phone/Fax

Practice location:
  • Phone: 708-585-9725
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096002960
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: