Healthcare Provider Details

I. General information

NPI: 1275049520
Provider Name (Legal Business Name): LAURA GALLARDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2017
Last Update Date: 12/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W COOK ST
MANTENO IL
60950-3720
US

IV. Provider business mailing address

681 DIVERSATECH DR N
MANTENO IL
60950-3554
US

V. Phone/Fax

Practice location:
  • Phone: 815-928-7200
  • Fax:
Mailing address:
  • Phone: 815-954-5602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: