Provider Demographics
NPI:1861409450
Name:UNIVERSITY OF ILLINOIS
Entity type:Organization
Organization Name:UNIVERSITY OF ILLINOIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL EDUCATION
Authorized Official - Prefix:
Authorized Official - First Name:CLARION
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDES
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:217-333-2205
Mailing Address - Street 1:2001 S OAK ST STE B
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-0912
Mailing Address - Country:US
Mailing Address - Phone:217-333-2205
Mailing Address - Fax:217-333-2206
Practice Address - Street 1:2001 S OAK ST STE B
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-0912
Practice Address - Country:US
Practice Address - Phone:217-333-2205
Practice Address - Fax:217-333-2206
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-03
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147.000339231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty