Healthcare Provider Details

I. General information

NPI: 1972847002
Provider Name (Legal Business Name): NORTHWESTERN UNIVERSITY SLL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 CAMPUS DR
EVANSTON IL
60208-3550
US

IV. Provider business mailing address

2315 CAMPUS DR
EVANSTON IL
60208-3550
US

V. Phone/Fax

Practice location:
  • Phone: 847-491-3165
  • Fax: 847-467-7141
Mailing address:
  • Phone: 847-491-3165
  • Fax: 847-467-0410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: PROF. SUMITRAJIT DHAR
Title or Position: ASSOCIATE CHAIR
Credential: PHD
Phone: 847-491-2470