Provider Demographics
NPI:1053640870
Name:SHULTZ, ELISSA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:SHULTZ
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27W157 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-2051
Mailing Address - Country:US
Mailing Address - Phone:630-653-0028
Mailing Address - Fax:
Practice Address - Street 1:25 N. WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190
Practice Address - Country:US
Practice Address - Phone:630-933-6293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008330235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist