Healthcare Provider Details

I. General information

NPI: 1659635688
Provider Name (Legal Business Name): SUSAN MARY BICKLINE SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 06/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9515 HOLY CROSS LN BOX 99
BREESE IL
62230-3618
US

IV. Provider business mailing address

9515 HOLY CROSS LN BOX 99
BREESE IL
62230-3618
US

V. Phone/Fax

Practice location:
  • Phone: 618-526-4511
  • Fax: 618-526-2855
Mailing address:
  • Phone: 618-526-4511
  • Fax: 618-526-2855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146003579
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: