Provider Demographics
NPI:1255511283
Name:SPEECH & LEARNING CONNECTIONS
Entity type:Organization
Organization Name:SPEECH & LEARNING CONNECTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ONTIVEROS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:309-663-4172
Mailing Address - Street 1:2412 E WASHINGTON ST
Mailing Address - Street 2:8B
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4497
Mailing Address - Country:US
Mailing Address - Phone:309-663-4172
Mailing Address - Fax:
Practice Address - Street 1:2412 E WASHINGTON ST
Practice Address - Street 2:8B
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4497
Practice Address - Country:US
Practice Address - Phone:309-663-4172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146007682235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5732059OtherBLUE CROSS BLUE SHIELD IL