Organization
BLOOMINGTON-NORMAL SPEECH THERAPY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BASHA M ONTIVEROS M.S., CCC-SLP (OWNER)
(309) 830-5925
Entity
Organization
Contact information
Practice address
2416 E WASHINGTON ST STE C5, BLOOMINGTON, IL 61704-1629
(309) 830-5925
Mailing address
2416 E WASHINGTON ST STE C5, BLOOMINGTON, IL 61704-1629
(309) 830-5925
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1629083423
CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) - PRIOR NPI#
IL
Enumeration date
12/09/2020
Last updated
12/09/2020
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