Healthcare Provider Details

I. General information

NPI: 1255408746
Provider Name (Legal Business Name): SPEECH LANGUAGE FUNDAMENTALS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 08/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2923 198TH PL
LYNWOOD IL
60411-4546
US

IV. Provider business mailing address

2923 198TH PL
LYNWOOD IL
60411-4546
US

V. Phone/Fax

Practice location:
  • Phone: 708-299-4799
  • Fax:
Mailing address:
  • Phone: 708-299-4799
  • Fax: 708-849-6079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146007330
License Number StateIL

VIII. Authorized Official

Name: MRS. LINDA MARIE GOFORTH
Title or Position: DIRECTOR OF SERVICES/OWNER
Credential: MHS CCC-SLP/L
Phone: 708-299-4799