Provider Demographics
NPI:1659855898
Name:AUSTIN, THEA ANNE (MS, CCC-SLP/L)
Entity Type:Individual
Prefix:MRS
First Name:THEA
Middle Name:ANNE
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:MS, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 POCONO AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2381
Mailing Address - Country:US
Mailing Address - Phone:309-369-4694
Mailing Address - Fax:
Practice Address - Street 1:800 W RB GARRETT AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-2207
Practice Address - Country:US
Practice Address - Phone:309-672-6810
Practice Address - Fax:309-676-9831
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.008800235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146.008800OtherDEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION