Provider Demographics
NPI:1477220044
Name:MALLOW, CAROLINE MARIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:MARIE
Last Name:MALLOW
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 JULIANNE DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1524
Mailing Address - Country:US
Mailing Address - Phone:618-694-2382
Mailing Address - Fax:
Practice Address - Street 1:411 S COURT ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-2711
Practice Address - Country:US
Practice Address - Phone:618-993-2138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146016062235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
146016062OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION