Provider Demographics
NPI:1245067792
Name:EDDIE, THERESA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:EDDIE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:
Other - Last Name:EDDIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:3271 BECKIE DR SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-9004
Mailing Address - Country:US
Mailing Address - Phone:616-443-5367
Mailing Address - Fax:
Practice Address - Street 1:2880 WILSON AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1221
Practice Address - Country:US
Practice Address - Phone:616-300-5495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000534235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty