Healthcare Provider Details

I. General information

NPI: 1376255893
Provider Name (Legal Business Name): NATALEE R MITROVICH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S MAIN ST
WAUCONDA IL
60084-1825
US

IV. Provider business mailing address

109 S MAIN ST
WAUCONDA IL
60084-1825
US

V. Phone/Fax

Practice location:
  • Phone: 224-818-4432
  • Fax:
Mailing address:
  • Phone: 224-818-4432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: NATALEE MITROVICH
Title or Position: LICENSED CLINICAL PROFESSIONAL COUN
Credential: MA,LCPC
Phone: 224-818-4432