Provider Demographics
NPI:1578823449
Name:PETTINGER, STACY LYNNE (MA,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNNE
Last Name:PETTINGER
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 1:1825 JC KELLOG ST
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-8782
Mailing Address - Country:US
Mailing Address - Phone:815-895-0002
Mailing Address - Fax:
Practice Address - Street 1:1715 DEKALB AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-2736
Practice Address - Country:US
Practice Address - Phone:815-991-5760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.006059235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist