MEDICARE: COVENANT CARE THERAPY LTD.

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

General Provider Information

NPI Number	:	1700072006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COVENANT CARE THERAPY LTD.

Provider Business Mailing Address
First Line	:	1875 W 108TH PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-3331
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1875 W 108TH PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-3331
Country	:	US
Telephone Number	:	773-615-6433
Fax Number	:

Authorized Official
Title or Position	:	SPEECH PATHOLOGIST
Name	:	MRS. VANESSA R. HALLOM
Credential	:	MS. CCC-SLP/L
Telephone Number	:	773-615-6433

Provider Enumeration Date	:	09/20/2007
Last Update Date	:	09/20/2007

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Directions to “COVENANT CARE THERAPY LTD. ” Practice Location

Language	Start Address	Practice Location

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