Provider Demographics
NPI:1134637879
Name:DEITHLOFF, ILCE
Entity Type:Individual
Prefix:
First Name:ILCE
Middle Name:
Last Name:DEITHLOFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 ROSLYN RD
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-2827
Mailing Address - Country:US
Mailing Address - Phone:847-756-2790
Mailing Address - Fax:
Practice Address - Street 1:310 JAMES ST
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-2827
Practice Address - Country:US
Practice Address - Phone:847-842-3507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist