Provider Demographics
NPI:1962801597
Name:DIRKS, STACI L (SLP)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:L
Last Name:DIRKS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:L
Other - Last Name:SAWYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:603 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-1330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:603 E 19TH ST
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-1330
Practice Address - Country:US
Practice Address - Phone:815-441-0338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146011290235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist