Provider Demographics
NPI:1780199943
Name:DITSWORTH, TAMARA LYNN (MA-CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:LYNN
Last Name:DITSWORTH
Suffix:
Gender:F
Credentials:MA-CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4141 IL ROUTE 84 S
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:IL
Mailing Address - Zip Code:61041-9631
Mailing Address - Country:US
Mailing Address - Phone:815-858-9005
Mailing Address - Fax:815-858-9006
Practice Address - Street 1:4141 IL ROUTE 84 S
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:IL
Practice Address - Zip Code:61041-9631
Practice Address - Country:US
Practice Address - Phone:815-858-9005
Practice Address - Fax:815-858-9006
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.008524235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist