MEDICARE: STEPHANIE LYNN VACKICEV MA CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	146012278	IL

General Provider Information

NPI Number	:	1497428973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE LYNN VACKICEV MA CCC-SLP

Provider Business Mailing Address
First Line	:	2N474 PLEASANT AVE
Second Line	:
City	:	GLEN ELLYN
State	:	IL
Zip	:	60137-2851
Country	:	US
Telephone Number	:	630-379-7775
Fax Number	:

Provider Business Practice Location Address
First Line	:	8600 US HIGHWAY 14 STE 108
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60012-2700
Country	:	US
Telephone Number	:	630-379-7775
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2021
Last Update Date	:	07/29/2021

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