MEDICARE: KIMBERLY MITCHELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist		IL

General Provider Information

NPI Number	:	1700060571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY MITCHELL

Provider Business Mailing Address
First Line	:	6735 S OGLESBY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-1315
Country	:	US
Telephone Number	:	708-841-0347
Fax Number	:	708-260-9396

Provider Business Practice Location Address
First Line	:	6735 S OGLESBY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-1315
Country	:	US
Telephone Number	:	708-841-0347
Fax Number	:	708-260-9396

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2007
Last Update Date	:	12/28/2007

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Directions to “ KIMBERLY MITCHELL ” Practice Location

Language	Start Address	Practice Location

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