Basic Information
| Provider Information | |||||||||
| NPI: | 1053801514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARISON | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | KRISTINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MICKSCH | ||||||||
| OtherFirstName: | SARAH | ||||||||
| OtherMiddleName: | KRISTINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | B.S. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 506 S GLOVER AVE UNIT E | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618024460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475960445 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1400 W PARK ST | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173372000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2018 | ||||||||
| LastUpdateDate: | 05/10/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 242.004647 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.