Basic Information
| Provider Information | |||||||||
| NPI: | 1497923767 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF ILLINOIS SPEECH AND HEARING | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SPEECH-LANGUAGE PATHOLOGY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 S OAK ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618200906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173332205 | ||||||||
| FaxNumber: | 2173332206 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 S OAK ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618200906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173332205 | ||||||||
| FaxNumber: | 2173332206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2008 | ||||||||
| LastUpdateDate: | 08/27/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MENDES | ||||||||
| AuthorizedOfficialFirstName: | CLARION | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINICAL EDUCATION | ||||||||
| AuthorizedOfficialTelephone: | 2173332205 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF ILLINOIS | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | SLP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 146008043 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 146004209 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 146000794 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 146005525 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 146003459 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 328742120001 | 05 | IL | MEDICAID | 344384568001 | 05 | IL | MEDICAID | 399620438001 | 05 | IL | MEDICAID | 356589993001 | 05 | IL | MEDICAID | 386640092001 | 05 | IL | MEDICAID |