Provider Demographics
NPI:1912410226
Name:LEVELING, BONNIE JO (MA CCC/SLP)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:JO
Last Name:LEVELING
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 1:87 GRIMMIG RD
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2010
Mailing Address - Country:US
Mailing Address - Phone:618-257-9201
Mailing Address - Fax:
Practice Address - Street 1:87 GRIMMIG RD
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2010
Practice Address - Country:US
Practice Address - Phone:618-257-9201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146003513235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1467590166Medicaid