1306093752 NPI number — COLLEEN FRANCES WIELAND SLP

Table of content: COLLEEN FRANCES WIELAND SLP (NPI 1306093752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306093752 NPI number — COLLEEN FRANCES WIELAND SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIELAND
Provider First Name:
COLLEEN
Provider Middle Name:
FRANCES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1306093752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
549 N DEER RUN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALATINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60067-8673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-997-1146
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 N CHILDRENS PLZ
Provider Second Line Business Practice Location Address:
SUITE 701
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60614-3363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-836-8040
Provider Business Practice Location Address Fax Number:
708-836-8040
Provider Enumeration Date:
08/27/2008

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:  001880 , 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)

  • Identifier: 0665463 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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