Provider Demographics
NPI:1699031112
Name:RUKTANTICHOKE, STEPHANIE ELLEN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ELLEN
Last Name:RUKTANTICHOKE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ELLEN
Other - Last Name:BRIDGEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:7830 SAGEMARK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-4556
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14255 CICERO AVE
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60445-2154
Practice Address - Country:US
Practice Address - Phone:708-371-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146010926235Z00000X
TX105353235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist