Provider Demographics
NPI:1689767709
Name:MADDOX, STACIE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:STACIE
Middle Name:
Last Name:MADDOX
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 1:643 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-8129
Mailing Address - Country:US
Mailing Address - Phone:630-651-9334
Mailing Address - Fax:630-554-4819
Practice Address - Street 1:643 VISTA DR
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-8129
Practice Address - Country:US
Practice Address - Phone:630-651-9334
Practice Address - Fax:630-554-4819
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist