Basic Information
| Provider Information | |||||||||
| NPI: | 1659525301 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC ADULT REHABILITATION ASSOCIATES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SPEECH TREE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2423 GLENWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604355483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157259992 | ||||||||
| FaxNumber: | 8157259993 | ||||||||
| Practice Location | |||||||||
| Address1: | 2423 GLENWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604355483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157259992 | ||||||||
| FaxNumber: | 8157259993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2008 | ||||||||
| LastUpdateDate: | 11/07/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUZICH | ||||||||
| AuthorizedOfficialFirstName: | SHAUNA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8157259992 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS CCC SLP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 242001067 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.