Healthcare Provider Details

I. General information

NPI: 1548219454
Provider Name (Legal Business Name): VASILIKITSA ANTONOPOULOS M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 12/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N STATE ST 2E
CHICAGO IL
60610-8665
US

IV. Provider business mailing address

850 N STATE ST 2E
CHICAGO IL
60610-8665
US

V. Phone/Fax

Practice location:
  • Phone: 773-206-7997
  • Fax: 312-787-6371
Mailing address:
  • Phone: 773-206-7997
  • Fax: 312-787-6371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146008154
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: