Provider Demographics
NPI:1043505233
Name:MCILVAINE, TERRY L (AUD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:L
Last Name:MCILVAINE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 RENAISSANCE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2180
Mailing Address - Country:US
Mailing Address - Phone:269-982-3444
Mailing Address - Fax:269-982-3445
Practice Address - Street 1:511 RENAISSANCE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2180
Practice Address - Country:US
Practice Address - Phone:269-982-3444
Practice Address - Fax:269-982-3445
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000172231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist