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Individual

BASHA ONTIVEROS

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
M.S., CCC-SLP

Contact information

Practice address
2416 E WASHINGTON ST STE C5, BLOOMINGTON, IL 61704-1629
(913) 730-5925
(202) 931-7876
Mailing address
207 IMPERIAL DR, BLOOMINGTON, IL 61701-2029
(309) 830-5925

Taxonomy

Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
146007682
IL

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
5732059
BLUE CROSS
IL
Enumeration date
07/30/2006
Last updated
08/22/2022
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