Provider Demographics
NPI:1730754862
Name:CORAL PEDIATRIC THERAPY LLC
Entity type:Organization
Organization Name:CORAL PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:LAURA
Authorized Official - Last Name:GREGORIO-PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP/L
Authorized Official - Phone:815-201-2507
Mailing Address - Street 1:3230 SYCAMORE RD STE 164
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-9621
Mailing Address - Country:US
Mailing Address - Phone:815-201-2507
Mailing Address - Fax:
Practice Address - Street 1:558 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115
Practice Address - Country:US
Practice Address - Phone:815-201-2507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech