Provider Demographics
NPI:1902303837
Name:MANSON, MITCHELL LEMON (RBT)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:LEMON
Last Name:MANSON
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8601 S EXCHANGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3118
Mailing Address - Country:US
Mailing Address - Phone:312-813-0779
Mailing Address - Fax:
Practice Address - Street 1:8601 S EXCHANGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3118
Practice Address - Country:US
Practice Address - Phone:312-813-0779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-08
Last Update Date:2018-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-18-52334106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician