Healthcare Provider Details

I. General information

NPI: 1316420219
Provider Name (Legal Business Name): GEORGINA ZURLIENE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

642 PLUM LN
NEW BADEN IL
62265-1156
US

IV. Provider business mailing address

642 PLUM LN
NEW BADEN IL
62265-1156
US

V. Phone/Fax

Practice location:
  • Phone: 618-567-8772
  • Fax:
Mailing address:
  • Phone: 618-567-8772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number193083
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: