Basic Information
| Provider Information | |||||||||
| NPI: | 1699098764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURKE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | RUTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12911 E 900TH ST | ||||||||
| Address2: | |||||||||
| City: | MACOMB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614558907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098334101 | ||||||||
| FaxNumber: | 3098361589 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 E GRANT ST | ||||||||
| Address2: | |||||||||
| City: | MACOMB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614553313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098334101 | ||||||||
| FaxNumber: | 3098361589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2010 | ||||||||
| LastUpdateDate: | 03/03/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 146003793 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.