Provider Demographics
NPI:1790267532
Name:DUNNEBACK, KATHERINE S (SLP/L)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:S
Last Name:DUNNEBACK
Suffix:
Gender:F
Credentials:SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 151ST ST
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-1841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6020 151ST ST
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-1841
Practice Address - Country:US
Practice Address - Phone:708-687-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.008240235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL235Z00000XMedicaid