Provider Demographics
NPI:1902034127
Name:GEDRAITIS, NICOLE LUCIA (MHS,CCC-SLP/L)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LUCIA
Last Name:GEDRAITIS
Suffix:
Gender:F
Credentials:MHS,CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 MARY SENICA CT
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-9658
Mailing Address - Country:US
Mailing Address - Phone:630-229-7890
Mailing Address - Fax:815-714-6202
Practice Address - Street 1:7N127 WHISPERING TRL
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-6366
Practice Address - Country:US
Practice Address - Phone:630-229-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2018-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.001197235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist