Provider Demographics
NPI:1912072729
Name:ILLINOIS WISCONSIN SERTOMA REGIONAL CENTER FOR COMMUNICATIVE DISORDERS
Entity Type:Organization
Organization Name:ILLINOIS WISCONSIN SERTOMA REGIONAL CENTER FOR COMMUNICATIVE DISORDERS
Other - Org Name:SERTOMA SPEECH AND HEARING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:KALEEN
Authorized Official - Last Name:MORRISON
Authorized Official - Suffix:
Authorized Official - Credentials:EDD CCC-SLP
Authorized Official - Phone:708-599-9500
Mailing Address - Street 1:10409 SOUTH ROBERTS ROAD
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465
Mailing Address - Country:US
Mailing Address - Phone:708-599-9500
Mailing Address - Fax:708-599-2791
Practice Address - Street 1:10409 SOUTH ROBERTS ROAD
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465
Practice Address - Country:US
Practice Address - Phone:708-599-9500
Practice Address - Fax:708-599-2791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL231H00000X
IL146002791235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL344622092001Medicaid
K19599Medicare UPIN
IL930640Medicare ID - Type Unspecified
IL354423877001Medicaid
995520Medicare UPIN