Provider Demographics
NPI:1669616983
Name:ILLINOIS STATE UNIVERSITY
Entity type:Organization
Organization Name:ILLINOIS STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:VERTICCHIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-438-3266
Mailing Address - Street 1:275 S UNIVERSITY ST
Mailing Address - Street 2:CAMPUS BOX 4720
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61790-4720
Mailing Address - Country:US
Mailing Address - Phone:309-438-8641
Mailing Address - Fax:309-438-0575
Practice Address - Street 1:275 S UNIVERSITY ST
Practice Address - Street 2:CAMPUS BOX 4720
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790-4720
Practice Address - Country:US
Practice Address - Phone:309-438-8641
Practice Address - Fax:309-438-0575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-30
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty