Provider Demographics
NPI:1679783401
Name:ROM, PATRICIA SUSAN (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:SUSAN
Last Name:ROM
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 GARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3443
Mailing Address - Country:US
Mailing Address - Phone:847-256-3913
Mailing Address - Fax:
Practice Address - Street 1:1131 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2600
Practice Address - Country:US
Practice Address - Phone:847-322-3913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist