Healthcare Provider Details

I. General information

NPI: 1023883980
Provider Name (Legal Business Name): ROMARIC ALAIN KEUWO CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2023
Last Update Date: 12/02/2023
Certification Date: 12/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 S DORCHESTER AVE
CHICAGO IL
60615-4118
US

IV. Provider business mailing address

111 W WACKER DR APT 1612
CHICAGO IL
60601-1606
US

V. Phone/Fax

Practice location:
  • Phone: 773-966-5039
  • Fax:
Mailing address:
  • Phone: 913-271-2604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number242.006933
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: