Provider Demographics
NPI:1770152563
Name:RAVNIKAR, MYCALEEN RAYE
Entity type:Individual
Prefix:
First Name:MYCALEEN
Middle Name:RAYE
Last Name:RAVNIKAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N MCCLURG CT APT 1511
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4371
Mailing Address - Country:US
Mailing Address - Phone:815-570-1043
Mailing Address - Fax:
Practice Address - Street 1:400 N MCCLURG CT APT 1511
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4371
Practice Address - Country:US
Practice Address - Phone:815-570-1043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146016495235Z00000X
IL242006361235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty