Provider Demographics
NPI:1821690397
Name:BOOTLE, REILLY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REILLY
Middle Name:
Last Name:BOOTLE
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 1:1133 SOUTH BLVD APT 913
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-4281
Mailing Address - Country:US
Mailing Address - Phone:716-361-7727
Mailing Address - Fax:
Practice Address - Street 1:10300 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-1426
Practice Address - Country:US
Practice Address - Phone:708-425-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.014681235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist