Provider Demographics
NPI:1851878771
Name:TALLERICO, LINDSEY
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:
Last Name:TALLERICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDSEY
Other - Middle Name:
Other - Last Name:BRINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12 MATTERHORN DR
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:708 SAINT LOUIS ST
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-1427
Practice Address - Country:US
Practice Address - Phone:618-656-1182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146013653235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist