Healthcare Provider Details

I. General information

NPI: 1093961195
Provider Name (Legal Business Name): LAURA L SIRTOUT SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 CANAL ST
BEARDSTOWN IL
62618-2349
US

IV. Provider business mailing address

550 FRONTAGE RD SUITE 2415
NORTHFIELD IL
60093-1202
US

V. Phone/Fax

Practice location:
  • Phone: 217-323-1900
  • Fax: 217-323-1914
Mailing address:
  • Phone: 847-441-5593
  • Fax: 847-441-0734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146006425
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: