Healthcare Provider Details

I. General information

NPI: 1568710812
Provider Name (Legal Business Name): ALLISON LIWANAG SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 REVERE DR
NORTHBROOK IL
60062-1564
US

IV. Provider business mailing address

255 REVERE DR
NORTHBROOK IL
60062-1564
US

V. Phone/Fax

Practice location:
  • Phone: 847-412-4350
  • Fax:
Mailing address:
  • Phone: 847-412-4350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number242-002440
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: