Healthcare Provider Details

I. General information

NPI: 1821934597
Provider Name (Legal Business Name): FENICE DEIDRE HEDGEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 MOONLIGHT RD
MATTESON IL
60443-1283
US

IV. Provider business mailing address

121 MOONLIGHT RD
MATTESON IL
60443-1283
US

V. Phone/Fax

Practice location:
  • Phone: 708-715-6218
  • Fax:
Mailing address:
  • Phone: 708-715-6218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number217000431
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: