Provider Demographics
NPI:1801929336
Name:MIGHTY-HARMON, AUDREY NATASHA (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:NATASHA
Last Name:MIGHTY-HARMON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:9354 S BISHOP ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-5136
Mailing Address - Country:US
Mailing Address - Phone:773-445-0540
Mailing Address - Fax:773-445-0350
Practice Address - Street 1:9923 RIDGELAND AVE
Practice Address - Street 2:SUITE 131
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-1262
Practice Address - Country:US
Practice Address - Phone:773-412-9824
Practice Address - Fax:773-445-0350
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146-005187235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL100044415Medicaid
IL01635357OtherBLUE CROSS BLUE SHIELD