Provider Demographics
NPI:1912451857
Name:PADILLA, MIRANDA (MS CCC-SLP/L)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:PADILLA
Suffix:
Gender:F
Credentials:MS 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 1:2550 HARNISH DR
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-6870
Mailing Address - Country:US
Mailing Address - Phone:224-484-2553
Mailing Address - Fax:
Practice Address - Street 1:2550 HARNISH DR
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-6870
Practice Address - Country:US
Practice Address - Phone:224-484-2553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146012692235Z00000X
WI4190235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist