Provider Demographics
NPI:1457865909
Name:MOFFITT, BETH DALTON (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:DALTON
Last Name:MOFFITT
Suffix:
Gender:F
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 1:920 TRALEE CT
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3776
Mailing Address - Country:US
Mailing Address - Phone:847-336-1543
Mailing Address - Fax:847-336-1543
Practice Address - Street 1:200 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1785
Practice Address - Country:US
Practice Address - Phone:847-949-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.004399235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist