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General NPI Number Information
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NPI Number | 1912379355
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Entity Type | Organization
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Legal Business Name | JACI DALE SPEECH PATHOLOGY SERVICES, LLC
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Dates
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Enumeration Date | 10/26/2015
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Last Update Date | 10/26/2015
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Provider Practice Location Address
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Address Line | 701 S LEDFORD ST
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City | HARRISBURG
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State | IL
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Zip | 62946-2532
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Country | US
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Telephone | 618-253-7019
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Fax | 618-253-7019
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Provider Business Mailing Address
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Address Line | 701 S LEDFORD ST
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City | HARRISBURG
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State | IL
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Zip | 62946-2532
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Country | US
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Telephone | 618-253-7019
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Fax | 618-253-7019
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Authorized Official
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Title or Position | OWNER
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Name | MRS. JACI RAE DALE
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Credential | M.S., CCC-SLP
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Telephone | 618-253-7019
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 146.005513
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License Number State | IL
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