Provider Demographics
NPI:1629083423
Name:ONTIVEROS, BASHA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BASHA
Middle Name:
Last Name:ONTIVEROS
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 1:207 IMPERIAL DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-2029
Mailing Address - Country:US
Mailing Address - Phone:309-830-5925
Mailing Address - Fax:
Practice Address - Street 1:2416 E WASHINGTON ST STE C5
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-1629
Practice Address - Country:US
Practice Address - Phone:913-730-5925
Practice Address - Fax:202-931-7876
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146007682235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5732059OtherBLUE CROSS