MEDICARE: TAYLOR KIMBROUGH SLP

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	146010537	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	09932114	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1821378266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYLOR KIMBROUGH SLP

Provider Business Mailing Address
First Line	:	10733 REVERE RD
Second Line	:
City	:	MOKENA
State	:	IL
Zip	:	60448-1903
Country	:	US
Telephone Number	:	708-837-8869
Fax Number	:	708-694-7006

Provider Business Practice Location Address
First Line	:	10733 REVERE RD
Second Line	:
City	:	MOKENA
State	:	IL
Zip	:	60448-1903
Country	:	US
Telephone Number	:	708-837-8869
Fax Number	:	708-694-7006

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

Provider Enumeration Date	:	08/17/2011
Last Update Date	:	09/20/2022

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Directions to “ TAYLOR KIMBROUGH SLP” Practice Location

Language	Start Address	Practice Location

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