Provider Demographics
NPI:1871832147
Name:COLEMAN, BETHANIE JOY (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BETHANIE
Middle Name:JOY
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:BETHANIE
Other - Middle Name:JOY
Other - Last Name:LECUREUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:353 N DESPLAINES ST
Mailing Address - Street 2:APT 3109
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-1234
Mailing Address - Country:US
Mailing Address - Phone:215-435-4326
Mailing Address - Fax:
Practice Address - Street 1:353 N DESPLAINES ST
Practice Address - Street 2:APT 3109
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-1234
Practice Address - Country:US
Practice Address - Phone:215-435-4326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-06
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL011197235Z00000X
IL146011489235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist