Provider Demographics
NPI:1891526521
Name:GRIBBLE, DAPHNE MARIE WALLACE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:DAPHNE
Middle Name:MARIE WALLACE
Last Name:GRIBBLE
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 1:15934 CANAVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CREAL SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:62922-2506
Mailing Address - Country:US
Mailing Address - Phone:618-638-7303
Mailing Address - Fax:
Practice Address - Street 1:1201 PINE ST
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-1634
Practice Address - Country:US
Practice Address - Phone:618-273-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.007328235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist