Provider Demographics
NPI:1023366036
Name:PROVOST, CYNTHIA ANN (MHS, CCC, SLP/L)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANN
Last Name:PROVOST
Suffix:
Gender:F
Credentials:MHS, CCC, SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6345 E 2000N RD
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-7504
Mailing Address - Country:US
Mailing Address - Phone:815-939-9853
Mailing Address - Fax:815-935-7860
Practice Address - Street 1:400 S KENNEDY DR
Practice Address - Street 2:SUITE 600
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-2682
Practice Address - Country:US
Practice Address - Phone:815-935-7496
Practice Address - Fax:815-935-7860
Is Sole Proprietor?:No
Enumeration Date:2012-08-22
Last Update Date:2012-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.005338235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist