Provider Demographics
NPI:1316754914
Name:MOSSIDES, OLIVIA (MS, SLP - CCC)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:MOSSIDES
Suffix:
Gender:F
Credentials:MS, SLP - CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 N LA SALLE DR APT 709
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-6342
Mailing Address - Country:US
Mailing Address - Phone:630-853-4277
Mailing Address - Fax:
Practice Address - Street 1:836 W WELLINGTON AVE STE 3809
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-296-3066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146017384235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist