Provider Demographics
NPI:1124708771
Name:ROXY'S HOUSE AT BLUE HERON RANCH
Entity type:Organization
Organization Name:ROXY'S HOUSE AT BLUE HERON RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROXY
Authorized Official - Middle Name:
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-369-4496
Mailing Address - Street 1:13801 N 130 EAST RD
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:IL
Mailing Address - Zip Code:61849-7018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13801 N 130 EAST RD
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:IL
Practice Address - Zip Code:61849-7018
Practice Address - Country:US
Practice Address - Phone:217-431-5484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty