Provider Demographics
NPI:1528125754
Name:ILLICH, DAVID M (AUD, CCCA)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:ILLICH
Suffix:
Gender:M
Credentials:AUD, CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 TIERRA LIBERTIA RD
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-7824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1045 E VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4618
Practice Address - Country:US
Practice Address - Phone:760-489-6901
Practice Address - Fax:760-489-1694
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU 778231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist