Provider Demographics
NPI:1962845784
Name:CONLISK, MARCIA DIANE (MSCCC-SLP/L)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:DIANE
Last Name:CONLISK
Suffix:
Gender:F
Credentials:MSCCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:CHENOA
Mailing Address - State:IL
Mailing Address - Zip Code:61726-1299
Mailing Address - Country:US
Mailing Address - Phone:217-418-9946
Mailing Address - Fax:
Practice Address - Street 1:215 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-2011
Practice Address - Country:US
Practice Address - Phone:815-844-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.004683235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist