Provider Demographics
NPI:1558478206
Name:GARDNER, JUDITH M (MA,CCC-SLP/L,C/NDT)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:M
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MA,CCC-SLP/L,C/NDT
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:
Other - Last Name:GEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:830 S ADDISON AVE
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-2877
Mailing Address - Country:US
Mailing Address - Phone:630-620-4433
Mailing Address - Fax:630-620-1148
Practice Address - Street 1:830 S ADDISON AVE
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-2877
Practice Address - Country:US
Practice Address - Phone:630-620-4433
Practice Address - Fax:630-620-1148
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146-000245235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146000245OtherSLP LICENSE