Provider Demographics
NPI:1063822260
Name:WOODSTOCK STUTTERING SPECIALIST
Entity Type:Organization
Organization Name:WOODSTOCK STUTTERING SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SLP/SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:815-403-1135
Mailing Address - Street 1:110 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3305
Mailing Address - Country:US
Mailing Address - Phone:815-308-5477
Mailing Address - Fax:815-334-1136
Practice Address - Street 1:110 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3305
Practice Address - Country:US
Practice Address - Phone:815-308-5477
Practice Address - Fax:815-334-1136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.006432235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1568616944OtherINDIVIDUAL NPI