Basic Information
| Provider Information | |||||||||
| NPI: | 1144837840 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CIANCIOLO | ||||||||
| FirstName: | PAIGE | ||||||||
| MiddleName: | AVERY | ||||||||
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| Credential: | CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 416501 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022416001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142944050 | ||||||||
| FaxNumber: | 6317608306 | ||||||||
| Practice Location | |||||||||
| Address1: | 1442 OLD SKOKIE RD | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600353032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477076744 | ||||||||
| FaxNumber: | 8477862156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2020 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 242006120 | IL | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 146016142 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 1221901 | 05 | IL | MEDICAID |