Provider Demographics
NPI:1316373137
Name:LAKEVIEW SPEECH AND LANGUAGE CLINIC, LLC
Entity Type:Organization
Organization Name:LAKEVIEW SPEECH AND LANGUAGE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUMBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP/L
Authorized Official - Phone:773-573-7709
Mailing Address - Street 1:550 W SURF ST
Mailing Address - Street 2:#405
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 W SURF ST
Practice Address - Street 2:#405
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6036
Practice Address - Country:US
Practice Address - Phone:773-573-7709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-25
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146010427235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty