1205059714 NPI number — MRS. MARCY ATIA RAK SPEECH LANGUAGE PATH

Table of content: MRS. MARCY ATIA RAK SPEECH LANGUAGE PATH (NPI 1205059714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205059714 NPI number — MRS. MARCY ATIA RAK SPEECH LANGUAGE PATH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAK
Provider First Name:
MARCY
Provider Middle Name:
ATIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
SPEECH LANGUAGE PATH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RAK
Provider Other First Name:
MARCY
Provider Other Middle Name:
ATIA
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DEVELOPMENTAL THERAP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1205059714
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 COPPER BEND ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62062-5688
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-792-3503
Provider Business Mailing Address Fax Number:
618-288-9276

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 COPPER BEND ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62062-5688
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-792-3503
Provider Business Practice Location Address Fax Number:
618-288-9276
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 222Q00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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