=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285205518
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CALLIE GRACE LANKFORD M.S., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2021
-----------------------------------------------------
Last Update Date | 07/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 E ORANGE ST
-----------------------------------------------------
City | HOOPESTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60942-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-497-6043
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1840 GREENBRIER AVE
-----------------------------------------------------
City | WEST LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47906-4820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-497-6043
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 146012840
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------