Provider Demographics
NPI:1760793483
Name:TELTING, DIDERIKA M (PHD, CCC-SLP)
Entity Type:Individual
Prefix:DR
First Name:DIDERIKA
Middle Name:M
Last Name:TELTING
Suffix:
Gender:F
Credentials:PHD, CCC-SLP
Other - Prefix:DR
Other - First Name:DEE
Other - Middle Name:M
Other - Last Name:TELTING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, CCC-SLP
Mailing Address - Street 1:1531 E BRADFORD PKWY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6853
Mailing Address - Country:US
Mailing Address - Phone:417-883-0043
Mailing Address - Fax:417-883-0043
Practice Address - Street 1:1531 E BRADFORD PKWY
Practice Address - Street 2:SUITE 205
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6853
Practice Address - Country:US
Practice Address - Phone:417-883-0043
Practice Address - Fax:417-883-0043
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01983235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist