Healthcare Provider Details

I. General information

NPI: 1316857162
Provider Name (Legal Business Name): ANJALI MUTHOLAM M.S., CF-SLP
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19162 88TH AVE
MOKENA IL
60448-8135
US

IV. Provider business mailing address

17128 KROPP CT
ORLAND PARK IL
60467-6001
US

V. Phone/Fax

Practice location:
  • Phone: 815-464-6069
  • Fax:
Mailing address:
  • Phone: 815-464-6069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number242.018836
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: