Healthcare Provider Details

I. General information

NPI: 1164548376
Provider Name (Legal Business Name): DEBORAH PROVENZANO SLPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9736 S HAMILTON AVE
CHICAGO IL
60643-1644
US

IV. Provider business mailing address

9736 S HAMILTON AVE
CHICAGO IL
60643-1644
US

V. Phone/Fax

Practice location:
  • Phone: 773-343-8484
  • Fax: 773-305-0954
Mailing address:
  • Phone: 773-343-8484
  • Fax: 773-305-0954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: