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General NPI Number Information
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NPI Number | 1255511283
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Entity Type | Organization
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Legal Business Name | SPEECH & LEARNING CONNECTIONS
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Dates
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Enumeration Date | 11/07/2007
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Last Update Date | 07/25/2008
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Provider Practice Location Address
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Address Line | 2412 E WASHINGTON ST 8B
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City | BLOOMINGTON
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State | IL
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Zip | 61704-4497
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Country | US
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Telephone | 309-663-4172
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Fax |
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Provider Business Mailing Address
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Address Line | 2412 E WASHINGTON ST 8B
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City | BLOOMINGTON
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State | IL
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Zip | 61704-4497
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Country | US
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Telephone | 309-663-4172
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Fax |
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Authorized Official
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Title or Position | DIRECTOR/OWNER
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Name | BASHA ONTIVEROS
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Credential | M.S., CCC-SLP
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Telephone | 309-663-4172
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 146007682
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License Number State | IL
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