=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306259155
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GENEVIEVE LAUREN RUBIN M.S., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2014
-----------------------------------------------------
Last Update Date | 06/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1957 W DICKENS AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-3934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-789-9640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1661 ROWNTREE LN
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-2760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-262-8777
-----------------------------------------------------
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 | 146.011819
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------