Provider Demographics
NPI:1295893683
Name:TITUS, COLETTE A (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:COLETTE
Middle Name:A
Last Name:TITUS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 DEMPSEY PL
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-1094
Mailing Address - Country:US
Mailing Address - Phone:630-208-0157
Mailing Address - Fax:
Practice Address - Street 1:538 DEMPSEY PL
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-1094
Practice Address - Country:US
Practice Address - Phone:630-208-0157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04532288OtherBLUE CROSS BLUE SHIELD