Provider Demographics
NPI:1417765967
Name:DISCO TECH LLC
Entity type:Organization
Organization Name:DISCO TECH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:262-623-7337
Mailing Address - Street 1:2536 N SAWYER AVE APT 207
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-6592
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2536 N SAWYER AVE APT 207
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-6592
Practice Address - Country:US
Practice Address - Phone:262-623-7337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty