Provider Demographics
NPI:1982756417
Name:NORTHERN ILLINOIS UNIVERSITY
Entity Type:Organization
Organization Name:NORTHERN ILLINOIS UNIVERSITY
Other - Org Name:SPEECH AND HEARING CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:JULIANN
Authorized Official - Last Name:SCHAIRER
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:815-753-6528
Mailing Address - Street 1:1 LUCINDA AVENUE
Mailing Address - Street 2:NORTHERN ILLINOIS UNIVERSITY
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115
Mailing Address - Country:US
Mailing Address - Phone:815-753-1481
Mailing Address - Fax:815-753-1664
Practice Address - Street 1:1 LUCINDA AVENUE
Practice Address - Street 2:NORTHERN ILLINOIS UNIVERSITY
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115
Practice Address - Country:US
Practice Address - Phone:815-753-1481
Practice Address - Fax:815-753-1664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL397581129001Medicaid