Provider Demographics
NPI:1760754691
Name:PHELPS, DEANNA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:PHELPS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 TIMBER RIDGE DR
Mailing Address - Street 2:# 3
Mailing Address - City:GRAFTON
Mailing Address - State:IL
Mailing Address - Zip Code:62037-1134
Mailing Address - Country:US
Mailing Address - Phone:618-977-5286
Mailing Address - Fax:
Practice Address - Street 1:401 TIMBER RIDGE DR
Practice Address - Street 2:# 3
Practice Address - City:GRAFTON
Practice Address - State:IL
Practice Address - Zip Code:62037-1134
Practice Address - Country:US
Practice Address - Phone:618-977-5286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01110235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO01110OtherSTATE OF MISSOURI, MISSOURI BOARD OF HEALING ARTS