Provider Demographics
NPI:1669088092
Name:PETTY, WILLIAM (CCC-SLP)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:PETTY
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28100 TORCH PKWY STE 600
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-4030
Mailing Address - Country:US
Mailing Address - Phone:602-617-8215
Mailing Address - Fax:
Practice Address - Street 1:28100 TORCH PKWY STE 600
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-4030
Practice Address - Country:US
Practice Address - Phone:602-617-8215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist