Provider Demographics
NPI:1508012352
Name:PARKS, DEIDRA DAWN (MS CCC/SLP)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:DAWN
Last Name:PARKS
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16721 E KENDALL RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2077
Mailing Address - Country:US
Mailing Address - Phone:618-214-2883
Mailing Address - Fax:
Practice Address - Street 1:16721 E KENDALL RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2077
Practice Address - Country:US
Practice Address - Phone:618-214-2883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.005992235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist