Provider Demographics
NPI:1124700240
Name:FANTASTIC SPEECH & LANGUAGE THERAPY PLLC
Entity type:Organization
Organization Name:FANTASTIC SPEECH & LANGUAGE THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:STEFANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TYBURCZY
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:815-919-6155
Mailing Address - Street 1:6210 BLACK HILL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-5629
Mailing Address - Country:US
Mailing Address - Phone:815-919-6155
Mailing Address - Fax:
Practice Address - Street 1:6210 BLACK HILL RIDGE DR
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60586-5629
Practice Address - Country:US
Practice Address - Phone:815-919-6155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty