Provider Demographics
NPI:1588836076
Name:BICOUVARIS, MARIA NICOLE (SLP)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:NICOLE
Last Name:BICOUVARIS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-2265
Mailing Address - Country:US
Mailing Address - Phone:815-338-1707
Mailing Address - Fax:
Practice Address - Street 1:708 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-2265
Practice Address - Country:US
Practice Address - Phone:815-338-1707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362264411001Medicaid
IL05615103OtherBLUE CROSS BLUE SHIELD
IL147296Medicare Oscar/Certification