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General NPI Number Information
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NPI Number | 1336745892
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Entity Type | Organization
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Legal Business Name | BLOOMINGTON-NORMAL SPEECH THERAPY LLC
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Dates
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Enumeration Date | 12/09/2020
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Last Update Date | 12/09/2020
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Provider Practice Location Address
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Address Line | 2416 E WASHINGTON ST STE C5
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City | BLOOMINGTON
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State | IL
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Zip | 61704-1629
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Country | US
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Telephone | 309-830-5925
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Fax |
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Provider Business Mailing Address
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Address Line | 2416 E WASHINGTON ST STE C5
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City | BLOOMINGTON
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State | IL
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Zip | 61704-1629
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Country | US
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Telephone | 309-830-5925
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BASHA M ONTIVEROS
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Credential | M.S., CCC-SLP
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Telephone | 309-830-5925
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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 |
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License Number State |
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