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General NPI Number Information
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NPI Number | 1609943380
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Entity Type | Organization
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Legal Business Name | SOUTHLAKE SPEECH & HEARING CENTER, INC
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Dates
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Enumeration Date | 11/29/2006
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Last Update Date | 06/20/2013
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Provider Practice Location Address
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Address Line | 99 E 86TH AVE SUITE A
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City | MERRILLVILLE
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State | IN
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Zip | 46410-6381
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Country | US
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Telephone | 219-738-2528
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Fax | 219-756-7825
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Provider Business Mailing Address
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Address Line | 99 E 86TH AVE SUITE A
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City | MERRILLVILLE
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State | IN
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Zip | 46410-6381
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Country | US
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Telephone | 219-738-2528
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Fax | 219-756-7825
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Authorized Official
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Title or Position | AUDIOLOGIST
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Name | JACLIN K. PROCTOR
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Credential | M.A., CCC-A
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Telephone | 219-738-2528
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | 481-20
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License Number State | IN
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