Healthcare Provider Details

I. General information

NPI: 1124496674
Provider Name (Legal Business Name): ALPHABET AVENUE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 E STATE ST
SYCAMORE IL
60178-9502
US

IV. Provider business mailing address

1225 E STATE ST
SYCAMORE IL
60178-9502
US

V. Phone/Fax

Practice location:
  • Phone: 815-517-7653
  • Fax:
Mailing address:
  • Phone: 815-517-7653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MS. KIM MARIE MEINKE
Title or Position: OWNER
Credential:
Phone: 815-517-7653