Basic Information
| Provider Information | |||||||||
| NPI: | 1922643188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOSIK | ||||||||
| FirstName: | CARLEY | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | SHEEHAN | ||||||||
| OtherFirstName: | CARLEY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5 REVERE DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600628005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478073717 | ||||||||
| FaxNumber: | 8473483706 | ||||||||
| Practice Location | |||||||||
| Address1: | 3130 CHATHAM RD STE A | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627045379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157259992 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2019 | ||||||||
| LastUpdateDate: | 11/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | 217000336 | IL | Y | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
No ID Information.