Provider Demographics
NPI:1790427805
Name:CRADDOCK, ROGER GARREN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:GARREN
Last Name:CRADDOCK
Suffix:
Gender:M
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 1:24 PINE TREE RD
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-9639
Mailing Address - Country:US
Mailing Address - Phone:309-854-2522
Mailing Address - Fax:
Practice Address - Street 1:24 PINE TREE RD
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-9639
Practice Address - Country:US
Practice Address - Phone:309-854-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-09
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14431547235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist