Healthcare Provider Details

I. General information

NPI: 1609943380
Provider Name (Legal Business Name): SOUTHLAKE SPEECH & HEARING CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 E 86TH AVE SUITE A
MERRILLVILLE IN
46410-6381
US

IV. Provider business mailing address

99 E 86TH AVE SUITE A
MERRILLVILLE IN
46410-6381
US

V. Phone/Fax

Practice location:
  • Phone: 219-738-2528
  • Fax: 219-756-7825
Mailing address:
  • Phone: 219-738-2528
  • Fax: 219-756-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number481-20
License Number StateIN

VIII. Authorized Official

Name: JACLIN K. PROCTOR
Title or Position: AUDIOLOGIST
Credential: M.A., CCC-A
Phone: 219-738-2528