Provider Demographics
NPI:1306416730
Name:IVANIC, BRIDGET O'SHEA (SLP)
Entity Type:Individual
Prefix:MRS
First Name:BRIDGET
Middle Name:O'SHEA
Last Name:IVANIC
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-6179
Mailing Address - Country:US
Mailing Address - Phone:815-218-7164
Mailing Address - Fax:
Practice Address - Street 1:2728 HASSERT BLVD STE 120
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-5317
Practice Address - Country:US
Practice Address - Phone:630-305-8399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242006380235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist