Provider Demographics
NPI:1750900585
Name:O'BANNON, RACHEL ELIZABETH (MS CCC-SLP CBIS)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:ELIZABETH
Last Name:O'BANNON
Suffix:
Gender:F
Credentials:MS CCC-SLP CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 MAPLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3186
Mailing Address - Country:US
Mailing Address - Phone:618-792-4568
Mailing Address - Fax:
Practice Address - Street 1:12380 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2511
Practice Address - Country:US
Practice Address - Phone:314-447-9741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-12
Last Update Date:2020-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018016956235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist