Provider Demographics
NPI:1780973925
Name:EHNLE, MIKELL RYANNE (PSYD)
Entity type:Individual
Prefix:DR
First Name:MIKELL
Middle Name:RYANNE
Last Name:EHNLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 S MAIN ST
Mailing Address - Street 2:APT C
Mailing Address - City:EUREKA
Mailing Address - State:IL
Mailing Address - Zip Code:61530-1633
Mailing Address - Country:US
Mailing Address - Phone:847-848-0203
Mailing Address - Fax:
Practice Address - Street 1:3716 W BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2938
Practice Address - Country:US
Practice Address - Phone:309-692-7755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008074103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist