Provider Demographics
NPI:1053759191
Name:DIETZ, DANIELLE GRACE (CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:DANIELLE
Middle Name:GRACE
Last Name:DIETZ
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2591 COMPASS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-8043
Mailing Address - Country:US
Mailing Address - Phone:847-729-6220
Mailing Address - Fax:847-729-1116
Practice Address - Street 1:2591 COMPASS RD STE 100
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-8043
Practice Address - Country:US
Practice Address - Phone:847-729-6220
Practice Address - Fax:847-729-1116
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146011166235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist