Provider Demographics
NPI:1497923767
Name:UNIVERSITY OF ILLINOIS SPEECH AND HEARING
Entity Type:Organization
Organization Name:UNIVERSITY OF ILLINOIS SPEECH AND HEARING
Other - Org Name:SPEECH-LANGUAGE PATHOLOGY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CLINICAL EDUCATION
Authorized Official - Prefix:
Authorized Official - First Name:CLARION
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDES
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:217-333-2205
Mailing Address - Street 1:2001 S OAK ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-0906
Mailing Address - Country:US
Mailing Address - Phone:217-333-2205
Mailing Address - Fax:217-333-2206
Practice Address - Street 1:2001 S OAK ST
Practice Address - Street 2:SUITE B
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-0906
Practice Address - Country:US
Practice Address - Phone:217-333-2205
Practice Address - Fax:217-333-2206
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-20
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146003459235Z00000X
IL146008043235Z00000X
IL146004209235Z00000X
IL146000794235Z00000X
IL146005525235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL328742120001Medicaid
IL344384568001Medicaid
IL399620438001Medicaid
IL356589993001Medicaid
IL386640092001Medicaid