Provider Demographics
NPI:1487772828
Name:WACHHOLDER, KATHIE JANE (MA CCC SLP)
Entity type:Individual
Prefix:
First Name:KATHIE
Middle Name:JANE
Last Name:WACHHOLDER
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:GILBERTS
Mailing Address - State:IL
Mailing Address - Zip Code:60136-4037
Mailing Address - Country:US
Mailing Address - Phone:847-697-6473
Mailing Address - Fax:
Practice Address - Street 1:100 SUMMIT DR
Practice Address - Street 2:
Practice Address - City:GILBERTS
Practice Address - State:IL
Practice Address - Zip Code:60136-4037
Practice Address - Country:US
Practice Address - Phone:847-697-6473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004532306OtherBCBS PROVIDER ID