Healthcare Provider Details

I. General information

NPI: 1790571107
Provider Name (Legal Business Name): BLOOMINGTON PEDIATRIC SPEECH THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3002 GE RD STE 2
BLOOMINGTON IL
61704-2502
US

IV. Provider business mailing address

26 WATERSIDE CIR
BLOOMINGTON IL
61704-2921
US

V. Phone/Fax

Practice location:
  • Phone: 309-530-6982
  • Fax:
Mailing address:
  • Phone: 309-530-6982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LESLIE GARTHAUS
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: CCC-SLP
Phone: 309-530-6982