Provider Demographics
NPI:1447521414
Name:PROVIDER CONNECTION
Entity type:Organization
Organization Name:PROVIDER CONNECTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEVELOPMENTAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MITCHEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-853-9832
Mailing Address - Street 1:1036 N HAMLIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-3830
Mailing Address - Country:US
Mailing Address - Phone:773-853-9832
Mailing Address - Fax:
Practice Address - Street 1:1036 N. HAMLIN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-3830
Practice Address - Country:US
Practice Address - Phone:773-853-9832
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency