Provider Demographics
NPI:1083129894
Name:GARRISON, VICKY LYNN (SLP)
Entity Type:Individual
Prefix:MRS
First Name:VICKY
Middle Name:LYNN
Last Name:GARRISON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 E 14TH RD
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-9524
Mailing Address - Country:US
Mailing Address - Phone:815-795-0728
Mailing Address - Fax:
Practice Address - Street 1:174 OAK ST
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:IL
Practice Address - Zip Code:61360-9500
Practice Address - Country:US
Practice Address - Phone:815-357-8744
Practice Address - Fax:815-357-1516
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.007712235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist