Provider Demographics
NPI:1679087662
Name:BROWN, DONNA MALLENE
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MALLENE
Last Name:BROWN
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 1:512 S POPLAR CIR
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-1675
Mailing Address - Country:US
Mailing Address - Phone:815-468-3664
Mailing Address - Fax:
Practice Address - Street 1:555 W COOK ST
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-3720
Practice Address - Country:US
Practice Address - Phone:815-928-7285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146005822235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist