Healthcare Provider Details

I. General information

NPI: 1407521917
Provider Name (Legal Business Name): MIXED INCLUSION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1749 BURR OAK RD
HOMEWOOD IL
60430-1810
US

IV. Provider business mailing address

1749 BURR OAK RD
HOMEWOOD IL
60430-1810
US

V. Phone/Fax

Practice location:
  • Phone: 832-599-4512
  • Fax:
Mailing address:
  • Phone: 832-599-4512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DR. CAMILLE O'QUIN
Title or Position: EXECUTIVE DIRECTOR, FOUNDER, SLP
Credential: ED.D., CCC-SLP
Phone: 832-599-4512