=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548946932
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOPHIE GHONEIM M.S CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2023
-----------------------------------------------------
Last Update Date | 06/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1969 W OGDEN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-864-3600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2053 W DIVISION ST APT 2
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-3157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-464-4005
-----------------------------------------------------
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 | 146.016857
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------