Provider Demographics
NPI:1346757374
Name:OTOOLE - GRANBERRY, CYNTHIA
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:OTOOLE - GRANBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:
Other - Last Name:OTOOLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3615 W GATE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-6162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3615 W GATE PKWY
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-6162
Practice Address - Country:US
Practice Address - Phone:815-229-2881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL235Z00000XMedicaid