Provider Demographics
NPI:1205061769
Name:NORTHERN ILLINOIS UNIVERSITY
Entity type:Organization
Organization Name:NORTHERN ILLINOIS UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEAN COLLEGE HEALTH & HUMAN SCIENCE
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHMOND
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:815-753-6155
Mailing Address - Street 1:3100 SYCAMORE ROAD
Mailing Address - Street 2:NIU SPEECH LANGUAGE HEARING CLINIC
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-2899
Mailing Address - Country:US
Mailing Address - Phone:815-753-1481
Mailing Address - Fax:815-753-1664
Practice Address - Street 1:3100 SYCAMORE ROAD
Practice Address - Street 2:NIU SPEECH LANGUAGE HEARING CLINIC
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-2899
Practice Address - Country:US
Practice Address - Phone:815-753-1483
Practice Address - Fax:815-753-1664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6011501Medicaid