Provider Demographics
NPI:1942936356
Name:MORTOTI, PRUDENCE BARBARA (MCD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PRUDENCE
Middle Name:BARBARA
Last Name:MORTOTI
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:PRUDENCE
Other - Middle Name:DELADEM
Other - Last Name:LAMPTEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11116 N STONE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-9797
Mailing Address - Country:US
Mailing Address - Phone:120-229-0416
Mailing Address - Fax:
Practice Address - Street 1:11116 N STONE CREEK DR
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525-9797
Practice Address - Country:US
Practice Address - Phone:120-229-0416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146015620235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist