Healthcare Provider Details

I. General information

NPI: 1235059007
Provider Name (Legal Business Name): CHARLOTTE LEE MCCOY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 BEECH DR
DIXON IL
61021-3934
US

IV. Provider business mailing address

1208 BEECH DR
DIXON IL
61021-3934
US

V. Phone/Fax

Practice location:
  • Phone: 815-625-6616
  • Fax:
Mailing address:
  • Phone: 815-973-9167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number242018740
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: