Provider Demographics
NPI:1609202266
Name:SPROULL, LYNETTE KATHLEEN (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:LYNETTE
Middle Name:KATHLEEN
Last Name:SPROULL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 WEBER DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-4103
Mailing Address - Country:US
Mailing Address - Phone:618-307-4961
Mailing Address - Fax:
Practice Address - Street 1:1501 WEBER DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-4103
Practice Address - Country:US
Practice Address - Phone:618-307-4961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146-005511235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist