Provider Demographics
NPI:1346614864
Name:MAMMOLITO, ANGELA PAOLA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:PAOLA
Last Name:MAMMOLITO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:MAMMOLITO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13400 S ROUTE 59
Mailing Address - Street 2:SUITE 116-326
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-5696
Mailing Address - Country:US
Mailing Address - Phone:815-267-7334
Mailing Address - Fax:630-429-9411
Practice Address - Street 1:13400 S ROUTE 59
Practice Address - Street 2:SUITE 116-326
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-5696
Practice Address - Country:US
Practice Address - Phone:815-267-7334
Practice Address - Fax:630-429-9411
Is Sole Proprietor?:No
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242003695235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL242003695OtherIL SLP LICENSE