Provider Demographics
NPI:1417616897
Name:ATHERTON, TINA (MS CCC-SLP/L)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:ATHERTON
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 KRAMER RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IL
Mailing Address - Zip Code:61415-8714
Mailing Address - Country:US
Mailing Address - Phone:309-264-2667
Mailing Address - Fax:
Practice Address - Street 1:145 S CHAMBERLAIN ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:IL
Practice Address - Zip Code:61473-9581
Practice Address - Country:US
Practice Address - Phone:309-426-2134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146007012235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist