Provider Demographics
NPI:1336627348
Name:STUMPF, NICHOLE CARRASQUILLO (MS, SLP-CCC)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:CARRASQUILLO
Last Name:STUMPF
Suffix:
Gender:F
Credentials:MS, SLP-CCC
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:MARIE
Other - Last Name:CARRASQUILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS SLP-CCC
Mailing Address - Street 1:265 S PALMER DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-2126
Mailing Address - Country:US
Mailing Address - Phone:708-200-9474
Mailing Address - Fax:
Practice Address - Street 1:265 S PALMER DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-2126
Practice Address - Country:US
Practice Address - Phone:708-200-9474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.014363235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist