Provider Demographics
NPI:1093123705
Name:PRAIRIE WIND SPEECH THERAPY, INC.
Entity Type:Organization
Organization Name:PRAIRIE WIND SPEECH THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST/FOUNDER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-840-4543
Mailing Address - Street 1:2109 NOEL DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-6552
Mailing Address - Country:US
Mailing Address - Phone:217-840-4543
Mailing Address - Fax:
Practice Address - Street 1:611 N DUNLAP AVE
Practice Address - Street 2:
Practice Address - City:SAVOY
Practice Address - State:IL
Practice Address - Zip Code:61874-8406
Practice Address - Country:US
Practice Address - Phone:217-840-4543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.004158235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty