Provider Demographics
NPI:1023506524
Name:COLLEEN A. MITCHELL PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:COLLEEN A. MITCHELL PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:773-387-0790
Mailing Address - Street 1:211 S. MAIN STREET SUITE 104
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1894
Mailing Address - Country:US
Mailing Address - Phone:773-387-0790
Mailing Address - Fax:
Practice Address - Street 1:211 S. MAIN STREET SUITE 104
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1894
Practice Address - Country:US
Practice Address - Phone:773-387-0790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty