Provider Demographics
NPI:1134687445
Name:MAHADEVAN, RENUKA
Entity Type:Individual
Prefix:
First Name:RENUKA
Middle Name:
Last Name:MAHADEVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 SAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-2844
Mailing Address - Country:US
Mailing Address - Phone:773-844-1183
Mailing Address - Fax:
Practice Address - Street 1:1112 SAYLOR ST
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-2844
Practice Address - Country:US
Practice Address - Phone:773-844-1183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.005203235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist