Provider Demographics
NPI:1184135899
Name:LITTLE, ODETTE (MA(CCC-SLP)L)
Entity type:Individual
Prefix:
First Name:ODETTE
Middle Name:
Last Name:LITTLE
Suffix:
Gender:F
Credentials:MA(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 1:1306 LINDSAY WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-1212
Mailing Address - Country:US
Mailing Address - Phone:815-861-1210
Mailing Address - Fax:
Practice Address - Street 1:206 S 10TH ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:IL
Practice Address - Zip Code:61061-1711
Practice Address - Country:US
Practice Address - Phone:815-732-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-20
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146001970235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01030246OtherASHA
IL146001970OtherIDFPR