Healthcare Provider Details

I. General information

NPI: 1144055526
Provider Name (Legal Business Name): MARY ANN STANLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2232 N CLYBOURN AVE
CHICAGO IL
60614-3193
US

IV. Provider business mailing address

2232 N CLYBOURN AVE
CHICAGO IL
60614-3193
US

V. Phone/Fax

Practice location:
  • Phone: 773-923-3509
  • Fax:
Mailing address:
  • Phone: 312-339-3055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4054
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146.028707
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: