Healthcare Provider Details

I. General information

NPI: 1457710063
Provider Name (Legal Business Name): LAKEVIEW SPEECH AND LANGUAGE CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2016
Last Update Date: 02/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 N CUYLER AVE
OAK PARK IL
60302-1408
US

IV. Provider business mailing address

822 N CUYLER AVE
OAK PARK IL
60302-1408
US

V. Phone/Fax

Practice location:
  • Phone: 773-573-7709
  • Fax:
Mailing address:
  • Phone: 773-573-7709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number56009800
License Number StateIL

VIII. Authorized Official

Name: TRACY TRUMBELL
Title or Position: OWNER
Credential: MA, CCC-SLP
Phone: 773-573-7709