Healthcare Provider Details

I. General information

NPI: 1629231840
Provider Name (Legal Business Name): CAROL RUCH WYLIE C.C.C./SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 11/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 ILLINI DR
EAST PEORIA IL
61611-1840
US

IV. Provider business mailing address

901 ILLINI DR
EAST PEORIA IL
61611-1840
US

V. Phone/Fax

Practice location:
  • Phone: 309-694-6446
  • Fax: 309-698-0650
Mailing address:
  • Phone: 309-694-6446
  • Fax: 309-698-0650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146003535
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: