Healthcare Provider Details

I. General information

NPI: 1740378074
Provider Name (Legal Business Name): BLOOMINGTON NORMAL AUDIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 09/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 EASTLAND DR SUITE 203
BLOOMINGTON IL
61701-3532
US

IV. Provider business mailing address

1404 EASTLAND DRIVE SUITE 203
BLOOMINGTON IL
61701
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-8346
  • Fax: 309-662-0479
Mailing address:
  • Phone: 309-662-8346
  • Fax: 309-662-0479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number147000437
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License Number147000437
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License Number147000437
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147000437
License Number StateIL

VIII. Authorized Official

Name: DR. DEBORAH S PITCHER
Title or Position: AUDIOLOGIST OWNER MANAGER
Credential: AUD
Phone: 309-662-8346