Provider Demographics
NPI:1437664059
Name:DEJONG, STACY IRENE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:IRENE
Last Name:DEJONG
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:IRENE
Other - Last Name:MAAG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18110 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-1511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20912 S FRANKFORT SQUARE RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-8123
Practice Address - Country:US
Practice Address - Phone:815-469-6993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146012745235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist