Provider Demographics
NPI:1538249305
Name:MITCHELL, LILLIAN R (MACCC-A)
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:R
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MACCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 S BROADWAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3875
Mailing Address - Country:US
Mailing Address - Phone:440-246-4327
Mailing Address - Fax:440-246-4327
Practice Address - Street 1:6100 S BROADWAY
Practice Address - Street 2:SUITE 102
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3874
Practice Address - Country:US
Practice Address - Phone:440-246-4327
Practice Address - Fax:440-246-4327
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA-0171231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0847329Medicaid
OHMI0410483Medicare ID - Type Unspecified
OH0847329Medicaid