Basic Information
| Provider Information | |||||||||
| NPI: | 1215560198 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUMMERS | ||||||||
| FirstName: | MARCI | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 504469 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631504469 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 PALM AVE | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619386031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172347403 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2020 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 146012467 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 146012467 | 01 | IL | IDFPR SPEECH PATHOLOGY LICENSE | OTHER |