Provider Demographics
NPI: | 1942359153 |
---|---|
Name: | LISTON, KATHLEEN S (MA, CCC-A) |
Entity Type: | Individual |
Prefix: | |
First Name: | KATHLEEN |
Middle Name: | S |
Last Name: | LISTON |
Suffix: | |
Gender: | F |
Credentials: | MA, CCC-A |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 5600 HICHITEE CT |
Mailing Address - Street 2: | |
Mailing Address - City: | LIBERTY TWP |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 45011-1282 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 847-267-8200 |
Mailing Address - Fax: | 847-267-9440 |
Practice Address - Street 1: | 775 WAUKEGAN RD |
Practice Address - Street 2: | SUITE 200 |
Practice Address - City: | DEERFIELD |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60015-4342 |
Practice Address - Country: | US |
Practice Address - Phone: | 847-267-8200 |
Practice Address - Fax: | 847-267-9440 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-01-09 |
Last Update Date: | 2008-05-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | A.00793 | 231H00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 231H00000X | Speech, Language and Hearing Service Providers | Audiologist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 000000543958 | Other | ANTHEM BCBS |
OH | 2710794 | Medicaid | |
OH | 000000513135 | Other | ANTHEM BCBS |
OH | P00376272 | Medicare PIN | |
OH | 2710794 | Medicaid | |
OH | LI4170472 | Medicare PIN |