Provider Demographics
NPI:1811582430
Name:FUNCTIONAL SPEECH THERAPY CO.
Entity type:Organization
Organization Name:FUNCTIONAL SPEECH THERAPY CO.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH THERAPY
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLISTCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:224-392-8707
Mailing Address - Street 1:1238 REGENT DR
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-2062
Mailing Address - Country:US
Mailing Address - Phone:224-392-8707
Mailing Address - Fax:
Practice Address - Street 1:1238 REGENT DR
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-2062
Practice Address - Country:US
Practice Address - Phone:224-392-8707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty