1295402022 NPI number — MRS. LYDIA GRACE CREECH MS, CF-SLP

Table of content: (NPI 1396124301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295402022 NPI number — MRS. LYDIA GRACE CREECH MS, CF-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CREECH
Provider First Name:
LYDIA
Provider Middle Name:
GRACE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, CF-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295402022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3517 N MARMORA AVE APT 1S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60634-4365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-887-2034
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
UNIT D
Provider Business Practice Location Address City Name:
LOMBARD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-652-0200
Provider Business Practice Location Address Fax Number:
630-652-0300
Provider Enumeration Date:
08/28/2021

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: 235Z00000X , with the licence number:  242.006595 , 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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