Provider Demographics
NPI:1194742007
Name:OSENGA, CANDICE J M (AUD)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:J M
Last Name:OSENGA
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CAMPUS BOX 4720
Mailing Address - Street 2:ECKELMANN-TAYLOR SPEECH AND HERAING CLINIC
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61790-4720
Mailing Address - Country:US
Mailing Address - Phone:309-438-8641
Mailing Address - Fax:309-438-5221
Practice Address - Street 1:275 SOUTH UNIVERSITY STREET
Practice Address - Street 2:211 RACHEL COOPER
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:309-438-8641
Practice Address - Fax:309-438-5221
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147-001150231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
207414OtherMEDICARE GROUP NO.
K24610Medicare ID - Type Unspecified