Blake Self, CCC-SLP

Primary specialty

Speech-Language PathologistTaxonomy code 235Z00000X

License

146012447 Issued in IL

Practice address

5704 Wonder Woods Drive
Wonder Lake, IL 60097

Phone

(847) 636-7603

NPI assigned

Dec 30, 2015

Last updated

Dec 30, 2015By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Self Talk Therapy Services PC

  • Speech-Language Pathologist
  • Crystal Lake, IL
  • NPI 1508310459
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1451433600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1451433600000",
    "number": "1164887592",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5704 WONDER WOODS DRIVE",
            "city": "WONDER LAKE",
            "state": "IL",
            "postal_code": "60097",
            "telephone_number": "847-636-7603"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5704 WONDER WOODS DRIVE",
            "city": "WONDER LAKE",
            "state": "IL",
            "postal_code": "60097",
            "telephone_number": "847-636-7603"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SELF",
        "first_name": "BLAKE",
        "credential": "CCC-SLP",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2015-12-30",
        "last_updated": "2015-12-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "IL",
            "license": "146012447",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kristin Mae Reid, M.S.
• Tanya Rettig, NP
• Jodie Saylor, DT
• James J Schroeder, DDS
• Deena C Schwartz, APRN, CRNA, PMHNP-BC
• Gregory V Sierminski, DDS
• Billie Noell Swanson, RBT-18-47448
• Alina Wanchoo
• Lois Jean Wenkel
• Wonder Lake Chiropractic, LLC

• Speech-Language Pathologist in Wonder Lake, IL
• Providers in Wonder Lake, IL by specialty
• Speech-Language Pathologist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 30, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.