Provider Demographics
NPI:1407524168
Name:RIDDLE, MIRANDA MAE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MAE
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12505 N 1500TH RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-8425
Mailing Address - Country:US
Mailing Address - Phone:325-212-3239
Mailing Address - Fax:
Practice Address - Street 1:12505 N 1500TH RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-8425
Practice Address - Country:US
Practice Address - Phone:325-212-3239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146016080235Z00000X
TX114598235Z00000X
IL146.016080235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist