Provider Demographics
NPI:1740308816
Name:COLLINS-WHITAKER, DEMETRIA (CCC-SLP/L)
Entity type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:
Last Name:COLLINS-WHITAKER
Suffix:
Gender:F
Credentials: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 1:3718 213TH PL
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-2575
Mailing Address - Country:US
Mailing Address - Phone:708-748-0470
Mailing Address - Fax:
Practice Address - Street 1:3718 213TH PL
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2575
Practice Address - Country:US
Practice Address - Phone:708-748-0470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242000261235Z00000X
IL146.009035235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist