Provider Demographics
NPI:1104312594
Name:AVIDOR-REISS, ILANIT (M SC, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ILANIT
Middle Name:
Last Name:AVIDOR-REISS
Suffix:
Gender:F
Credentials:M SC, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3427 GALLATIN RD
Mailing Address - Street 2:
Mailing Address - City:OTTAWA HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:43606-2443
Mailing Address - Country:US
Mailing Address - Phone:617-455-8772
Mailing Address - Fax:
Practice Address - Street 1:BGSU SPEECH AND HEARING CLINIC
Practice Address - Street 2:200 HEALTH CENTER BUILDING
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43403-0149
Practice Address - Country:US
Practice Address - Phone:419-372-2515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10424235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist