Provider Demographics
NPI:1336745892
Name:BLOOMINGTON-NORMAL SPEECH THERAPY LLC
Entity Type:Organization
Organization Name:BLOOMINGTON-NORMAL SPEECH THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BASHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ONTIVEROS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:309-830-5925
Mailing Address - Street 1:2416 E WASHINGTON ST STE C5
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-1629
Mailing Address - Country:US
Mailing Address - Phone:309-830-5925
Mailing Address - Fax:
Practice Address - Street 1:2416 E WASHINGTON ST STE C5
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-1629
Practice Address - Country:US
Practice Address - Phone:309-830-5925
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
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
IL1629083423OtherCENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) - PRIOR NPI#