Provider Demographics
NPI:1891353363
Name:INGRAM, MADELINE ROSE (MS SLP)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:ROSE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:
Other - Last Name:GOETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2862 S SOUTHBROOK DR
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-7198
Mailing Address - Country:US
Mailing Address - Phone:815-263-5001
Mailing Address - Fax:
Practice Address - Street 1:10 N LOCUST ST STE 2
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-1500
Practice Address - Country:US
Practice Address - Phone:815-263-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
IL242.007110235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician