Healthcare Provider Details

I. General information

NPI: 1073297420
Provider Name (Legal Business Name): SOPHIA DENAE LANTING M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1739 N ELSTON AVE
CHICAGO IL
60642-1544
US

IV. Provider business mailing address

17313 HOSHAW ST
LOWELL IN
46356-9399
US

V. Phone/Fax

Practice location:
  • Phone: 773-687-9241
  • Fax:
Mailing address:
  • Phone: 219-775-6902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146.017804
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: