Basic Information
| Provider Information | |||||||||
| NPI: | 1083700769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ETCHISON | ||||||||
| FirstName: | MONA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12255 S 80TH AVENUE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089237878 | ||||||||
| FaxNumber: | 7089237888 | ||||||||
| Practice Location | |||||||||
| Address1: | 12255 S 80TH AVENUE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089237878 | ||||||||
| FaxNumber: | 7089237888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | IL | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0991516762 | 01 | IL | BCBS | OTHER | 7229P | 01 | IL | CATERPILLAR | OTHER | 219043 | 01 | IL | MAGELLAN | OTHER | 536182 | 01 | IL | VALUE BEHAVIORAL HEALTH | OTHER |