Provider Demographics
NPI:1407974363
Name:ROODHOUSE, ELLEN DARLENE (SPEECH LANGUAGE PATH)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:DARLENE
Last Name:ROODHOUSE
Suffix:
Gender:F
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2351 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-3972
Mailing Address - Country:US
Mailing Address - Phone:309-353-5940
Mailing Address - Fax:
Practice Address - Street 1:2351 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-3972
Practice Address - Country:US
Practice Address - Phone:309-353-5940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146001816235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL537460014OtherMEDICARE PTAN