=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730318668
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNIFER M MAUCK DBA BLOOM INTO SPEECH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2009
-----------------------------------------------------
Last Update Date | 07/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 164 N MYRTLE AVE
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-2625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-771-2386
-----------------------------------------------------
Fax | 630-279-0357
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 164 N MYRTLE AVE
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-2625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-771-2386
-----------------------------------------------------
Fax | 630-279-0357
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING SERVICE
-----------------------------------------------------
Name | KARIN RICHTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-769-5316
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 146006465
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------