Healthcare Provider Details

I. General information

NPI: 1407916836
Provider Name (Legal Business Name): NORTHERN ILLINOIS UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SYCAMORE RD NIU SPEECH LANGUAGE HEARING CLINIC
DEKALB IL
60115-9621
US

IV. Provider business mailing address

3100 SYCAMORE RD NIU SPEECH LANGUAGE HEARING CLINIC
DEKALB IL
60115-9621
US

V. Phone/Fax

Practice location:
  • Phone: 815-753-1481
  • Fax: 815-753-1664
Mailing address:
  • Phone: 815-753-1481
  • Fax: 815-753-1664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: CARISSA NICOLE CALLAHAN
Title or Position: ASSISTANT TO THE DEAN
Credential:
Phone: 815-753-6161