Provider Demographics
NPI:1619480886
Name:ERICKSON-ZALE, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:ERICKSON-ZALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1N179 PAPWORTH ST
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-2318
Mailing Address - Country:US
Mailing Address - Phone:815-861-3175
Mailing Address - Fax:
Practice Address - Street 1:780 SHORELINE DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-6192
Practice Address - Country:US
Practice Address - Phone:630-375-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.006373235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146.006373OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION