Provider Demographics
NPI:1093149387
Name:VIRGINIA MIDDENDORFF D/B/A THERAPY-LEARNING CLINIC
Entity Type:Organization
Organization Name:VIRGINIA MIDDENDORFF D/B/A THERAPY-LEARNING CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDDENDORFF
Authorized Official - Suffix:
Authorized Official - Credentials:MS,CCC-SLP
Authorized Official - Phone:618-594-5561
Mailing Address - Street 1:1090 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CARLYLE
Mailing Address - State:IL
Mailing Address - Zip Code:62231-1426
Mailing Address - Country:US
Mailing Address - Phone:618-594-5561
Mailing Address - Fax:618-594-5561
Practice Address - Street 1:1090 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CARLYLE
Practice Address - State:IL
Practice Address - Zip Code:62231-1426
Practice Address - Country:US
Practice Address - Phone:618-594-5561
Practice Address - Fax:618-594-5561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.004800235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1912056375OtherINDIVIDUAL NPI