Provider Demographics
NPI:1174677413
Name:PEDERSON, VINCENT (CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18483 W GEIER RD
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-1305
Mailing Address - Country:US
Mailing Address - Phone:224-643-7713
Mailing Address - Fax:
Practice Address - Street 1:1442 OLD SKOKIE RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-3032
Practice Address - Country:US
Practice Address - Phone:847-486-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist