Provider Demographics
NPI:1497043111
Name:FAUNTLEROY, CAITLIN ELIZABETH
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:ELIZABETH
Last Name:FAUNTLEROY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 N MAPLEWOOD AVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3146
Mailing Address - Country:US
Mailing Address - Phone:615-519-1586
Mailing Address - Fax:
Practice Address - Street 1:1957 W DICKENS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3934
Practice Address - Country:US
Practice Address - Phone:773-698-6535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist