Provider Demographics
NPI:1164548376
Name:PROVENZANO, DEBORAH (SLPA)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9736 S HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1644
Mailing Address - Country:US
Mailing Address - Phone:773-343-8484
Mailing Address - Fax:773-305-0954
Practice Address - Street 1:9736 S HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1644
Practice Address - Country:US
Practice Address - Phone:773-343-8484
Practice Address - Fax:773-305-0954
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01635583OtherBLUE CROSS BLUE SHIELD