Provider Demographics
NPI:1700966520
Name:MITAN, ROBIN (OT)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:MITAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 MEADOWVIEW LANE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236
Mailing Address - Country:US
Mailing Address - Phone:618-806-8461
Mailing Address - Fax:
Practice Address - Street 1:891 MEADOWVIEW LANE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236
Practice Address - Country:US
Practice Address - Phone:618-806-8461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000155595225X00000X
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
06732018OtherBLUE CROSS BLUE SHIELD OF
7058311OtherAETNA