Provider Demographics
NPI:1558718023
Name:INDEPENDENT PROVIDER
Entity Type:Organization
Organization Name:INDEPENDENT PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLONEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS CF-SLP
Authorized Official - Phone:773-759-2403
Mailing Address - Street 1:3800 W 106TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-3815
Mailing Address - Country:US
Mailing Address - Phone:773-759-2403
Mailing Address - Fax:
Practice Address - Street 1:3800 W 106TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-3815
Practice Address - Country:US
Practice Address - Phone:773-759-2403
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-15
Last Update Date:2016-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242003723252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency