Provider Demographics
NPI:1124446240
Name:ML ETCHISON AND ASSOCIATES, INC.
Entity type:Organization
Organization Name:ML ETCHISON AND ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MONA
Authorized Official - Middle Name:LUAN
Authorized Official - Last Name:ETCHISON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:708-269-3050
Mailing Address - Street 1:745 N WAIOLA AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1451
Mailing Address - Country:US
Mailing Address - Phone:708-269-3050
Mailing Address - Fax:708-579-0169
Practice Address - Street 1:7350 W COLLEGE DR
Practice Address - Street 2:SUITE #106
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1149
Practice Address - Country:US
Practice Address - Phone:708-269-3050
Practice Address - Fax:708-579-0169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-05
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007027103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty