Healthcare Provider Details

I. General information

NPI: 1518322114
Provider Name (Legal Business Name): STEPHANIE GAEDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2015
Last Update Date: 12/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2980 N MAIN ST STE 4
DECATUR IL
62526-3291
US

IV. Provider business mailing address

2980 N MAIN ST STE 4
DECATUR IL
62526-3291
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-9902
  • Fax: 217-876-9903
Mailing address:
  • Phone: 217-876-9902
  • Fax: 217-876-9903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3237
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: