Provider Demographics
NPI:1093405896
Name:KOONS, KASANDRA (CF-SLP)
Entity Type:Individual
Prefix:
First Name:KASANDRA
Middle Name:
Last Name:KOONS
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:
Other - First Name:KASANDRA
Other - Middle Name:
Other - Last Name:STOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4422 E POWERS BLVD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-2545
Mailing Address - Country:US
Mailing Address - Phone:217-853-0727
Mailing Address - Fax:
Practice Address - Street 1:1145 ARBOR DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-9347
Practice Address - Country:US
Practice Address - Phone:217-872-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist