=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518528132
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOPHIE BARENIE MA CC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2019
-----------------------------------------------------
Last Update Date | 10/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 HEALTH CENTER DR
-----------------------------------------------------
City | MATTOON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61938-4644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-258-2568
-----------------------------------------------------
Fax | 217-238-3420
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1605 N WILLOW RD APT 315
-----------------------------------------------------
City | URBANA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61801-1134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-677-8185
-----------------------------------------------------
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 | 146-014970
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 242005130
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------