Provider Demographics
NPI:1699318022
Name:WILLGING, DEREK MICHAEL
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:MICHAEL
Last Name:WILLGING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12076 TRESEMER RD
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-8925
Mailing Address - Country:US
Mailing Address - Phone:815-601-9513
Mailing Address - Fax:
Practice Address - Street 1:11971 WAGON WHEEL RD
Practice Address - Street 2:
Practice Address - City:ROCKTON
Practice Address - State:IL
Practice Address - Zip Code:61072-3322
Practice Address - Country:US
Practice Address - Phone:815-624-2615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4965-154235Z00000X
IL242005649235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist