Provider Demographics
NPI:1366918682
Name:SPEECH SUITE 815
Entity type:Organization
Organization Name:SPEECH SUITE 815
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH AND LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:LUCIA
Authorized Official - Last Name:GEDRAITIS
Authorized Official - Suffix:
Authorized Official - Credentials:MHS, CCC-SLP/L
Authorized Official - Phone:630-229-7890
Mailing Address - Street 1:115 MARY SENICA CT
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-9658
Mailing Address - Country:US
Mailing Address - Phone:630-229-7890
Mailing Address - Fax:815-714-6202
Practice Address - Street 1:838 1ST ST
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-2508
Practice Address - Country:US
Practice Address - Phone:815-200-8830
Practice Address - Fax:815-714-6202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1902034127OtherPRIVATE INSURANCE