Provider Demographics
NPI:1326823311
Name:HERBOLSHEIMER, CHARLOTTE GRACE (MS CF-SLP)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:GRACE
Last Name:HERBOLSHEIMER
Suffix:
Gender:F
Credentials:MS CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W 15TH ST UNIT 140
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1447
Mailing Address - Country:US
Mailing Address - Phone:847-313-8655
Mailing Address - Fax:
Practice Address - Street 1:310 S MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-2692
Practice Address - Country:US
Practice Address - Phone:630-652-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242007554235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1477602548Medicaid