Provider Demographics
NPI:1841558335
Name:MACKLE, ELIZABETH (CCC-SLP-L)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:MACKLE
Suffix:
Gender:F
Credentials:CCC-SLP-L
Other - Prefix:
Other - First Name:LIZ
Other - Middle Name:
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CCC-SLP-L
Mailing Address - Street 1:214 NORMAN DR
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:IL
Mailing Address - Zip Code:61535-9770
Mailing Address - Country:US
Mailing Address - Phone:309-387-6975
Mailing Address - Fax:
Practice Address - Street 1:128 WASHINGTON SQ
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-2657
Practice Address - Country:US
Practice Address - Phone:800-773-1682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146000985235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist