MEDICARE: COLLEEN PROSEK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	146017927	IL

General Provider Information

NPI Number	:	1164230348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN PROSEK

Provider Business Mailing Address
First Line	:	300 COMMERCE DR
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3503
Country	:	US
Telephone Number	:	847-721-1658
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 COMMERCE DR
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3503
Country	:	US
Telephone Number	:	847-721-1658
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2024
Last Update Date	:	12/20/2024

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Directions to “ COLLEEN PROSEK ” Practice Location

Language	Start Address	Practice Location

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