Provider Demographics
NPI:1598270563
Name:GERECKE, CYNTHIA JANE (MS CCC-SLP/L)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:JANE
Last Name:GERECKE
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 E ELMWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1104
Mailing Address - Country:US
Mailing Address - Phone:708-647-7418
Mailing Address - Fax:
Practice Address - Street 1:940 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-1366
Practice Address - Country:US
Practice Address - Phone:708-647-7418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.003816235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1396962106Medicaid