=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770749178
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ANN RIZZUTO SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2008
-----------------------------------------------------
Last Update Date | 05/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2543 W 101ST ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60655-1043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-837-4412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2536 W 100TH PL
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60655-1032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-837-4412
-----------------------------------------------------
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 | 146009400
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------