Basic Information
| Provider Information | |||||||||
| NPI: | 1861409450 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF ILLINOIS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNIVERSITY OF ILLINOIS AUDIOLOGY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 S OAK ST STE B | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618200912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173332205 | ||||||||
| FaxNumber: | 2173332206 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 S OAK ST STE B | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618200912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173332205 | ||||||||
| FaxNumber: | 2173332206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| 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: | BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS | ||||||||
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| AuthorizedOfficialCredential: | CCC-SLP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 147.000339 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.