Healthcare Provider Details

I. General information

NPI: 1134953599
Provider Name (Legal Business Name): CARLY ELIZABETH DEDITZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 06/28/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 W LAKE AVE
GLENVIEW IL
60026-1292
US

IV. Provider business mailing address

5004 PYNDALE DR
MCHENRY IL
60050-5019
US

V. Phone/Fax

Practice location:
  • Phone: 847-998-6100
  • Fax:
Mailing address:
  • Phone: 815-382-5049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number242.007861
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: