Provider Demographics
NPI:1710353586
Name:REXROAD, CAITLIN JANE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:JANE
Last Name:REXROAD
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:JANE
Other - Last Name:REXROAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2405 CARISBROOKE DR
Mailing Address - Street 2:APT 12
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-2371
Mailing Address - Country:US
Mailing Address - Phone:314-630-5654
Mailing Address - Fax:
Practice Address - Street 1:1505 PATTON DR
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-8116
Practice Address - Country:US
Practice Address - Phone:217-586-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242003726235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist