Provider Demographics
NPI:1366829046
Name:GROSSMAN, STACY (MSCCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 BRISTOL LN
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1209
Mailing Address - Country:US
Mailing Address - Phone:847-767-8903
Mailing Address - Fax:
Practice Address - Street 1:1233 BRISTOL LN
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-1209
Practice Address - Country:US
Practice Address - Phone:847-767-8903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.005418235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist