Healthcare Provider Details

I. General information

NPI: 1477043669
Provider Name (Legal Business Name): DECEMBER MCCRACKEN CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 FOXWORTH BLVD APT 304
LOMBARD IL
60148-6433
US

IV. Provider business mailing address

109 S OAKLAND GRV
ELMHURST IL
60126-3011
US

V. Phone/Fax

Practice location:
  • Phone: 815-621-6869
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146.015565
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-29089
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: