Basic Information
| Provider Information | |||||||||
| NPI: | 1659635688 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BICKLINE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MARY | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9515 HOLY CROSS LN | ||||||||
| Address2: | BOX 99 | ||||||||
| City: | BREESE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622303618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185264511 | ||||||||
| FaxNumber: | 6185262855 | ||||||||
| Practice Location | |||||||||
| Address1: | 9515 HOLY CROSS LN | ||||||||
| Address2: | BOX 99 | ||||||||
| City: | BREESE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622303618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185264511 | ||||||||
| FaxNumber: | 6185262855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2012 | ||||||||
| LastUpdateDate: | 06/25/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 146003579 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.