Provider Demographics
NPI:1629623764
Name:HENTZEL, MORGAN RAE
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:RAE
Last Name:HENTZEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MORGAN
Other - Middle Name:RAE
Other - Last Name:WEIRATHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1027 DERRY LN APT 54
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-2683
Mailing Address - Country:US
Mailing Address - Phone:319-795-0990
Mailing Address - Fax:
Practice Address - Street 1:315 N BONHAM ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-1808
Practice Address - Country:US
Practice Address - Phone:309-833-2095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242005318235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist