Basic Information
| Provider Information | |||||||||
| NPI: | 1962758466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHENOWETH | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LARNEY | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 14847 MENARD AVE | ||||||||
| Address2: | |||||||||
| City: | OAK FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604521126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087690145 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11531 SWINFORD LN | ||||||||
| Address2: | |||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604489274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2192290322 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2012 | ||||||||
| LastUpdateDate: | 10/01/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 146.011206 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.