=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215089800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLAZING PRAIRIE STARS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 47W635 BEITH RD
-----------------------------------------------------
City | MAPLE PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60151-8802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-365-5550
-----------------------------------------------------
Fax | 630-365-9550
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47W635 BEITH ROAD
-----------------------------------------------------
City | MAPLE PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60151-8802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-365-5550
-----------------------------------------------------
Fax | 630-365-9550
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. CATHERINE B RAACK
-----------------------------------------------------
Credential | M.A.CCC-SLP
-----------------------------------------------------
Telephone | 630-365-5550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------