Provider Demographics
NPI:1497428973
Name:VACKICEV, STEPHANIE LYNN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:VACKICEV
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2N474 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-2851
Mailing Address - Country:US
Mailing Address - Phone:630-379-7775
Mailing Address - Fax:
Practice Address - Street 1:8600 US HIGHWAY 14 STE 108
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-2700
Practice Address - Country:US
Practice Address - Phone:630-379-7775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146012278235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty