Provider Demographics
NPI:1871569368
Name:TIS CHALLENGING SPEECH
Entity type:Organization
Organization Name:TIS CHALLENGING SPEECH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:RANE
Authorized Official - Last Name:BYERS SPRAETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC SLP
Authorized Official - Phone:815-541-1857
Mailing Address - Street 1:1706 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNA
Mailing Address - State:IL
Mailing Address - Zip Code:61074-2424
Mailing Address - Country:US
Mailing Address - Phone:815-541-1857
Mailing Address - Fax:561-994-9240
Practice Address - Street 1:1706 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:SAVANNA
Practice Address - State:IL
Practice Address - Zip Code:61074-2424
Practice Address - Country:US
Practice Address - Phone:815-541-1857
Practice Address - Fax:815-273-4354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL686816261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146589OtherMEDICARE OTHER
IL346488095Medicaid
FL890410300Medicaid
FL686816Medicare ID - Type Unspecified