=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962531962
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARY A. CRUM INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3447 N SEELEY AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-6113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-550-6987
-----------------------------------------------------
Fax | 773-244-1364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3447 N SEELEY AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-6113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-550-6987
-----------------------------------------------------
Fax | 773-244-1364
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH PATHOLOGIST
-----------------------------------------------------
Name | MS. MARY A CRUM
-----------------------------------------------------
Credential | MA CCC SLPL
-----------------------------------------------------
Telephone | 773-550-6987
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------