Provider Demographics
NPI:1215089800
Name:BLAZING PRAIRIE STARS
Entity type:Organization
Organization Name:BLAZING PRAIRIE STARS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:RAACK
Authorized Official - Suffix:
Authorized Official - Credentials:MACCC-SLP
Authorized Official - Phone:630-365-5550
Mailing Address - Street 1:47W635 BEITH ROAD
Mailing Address - Street 2:
Mailing Address - City:MAPLE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60151-8802
Mailing Address - Country:US
Mailing Address - Phone:630-365-5550
Mailing Address - Fax:630-365-9550
Practice Address - Street 1:47W635 BEITH RD
Practice Address - Street 2:
Practice Address - City:MAPLE PARK
Practice Address - State:IL
Practice Address - Zip Code:60151-8802
Practice Address - Country:US
Practice Address - Phone:630-365-5550
Practice Address - Fax:630-365-9550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04532110OtherBLUE CROSS BLUE SHEILD