Provider Demographics
NPI:1295829901
Name:BACON, MARY J (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:BACON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 W ADELAIDE ST
Mailing Address - Street 2:UNIT 103
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-3306
Mailing Address - Country:US
Mailing Address - Phone:708-212-1412
Mailing Address - Fax:
Practice Address - Street 1:1611 W HARRISON ST
Practice Address - Street 2:SUITE 530
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:312-942-5332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.001425235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist