1699031112 NPI number — STEPHANIE ELLEN RUKTANTICHOKE CCC-SLP

Table of content: DR. KENYA DENISE GARCIA OD (NPI 1689406878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699031112 NPI number — STEPHANIE ELLEN RUKTANTICHOKE CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUKTANTICHOKE
Provider First Name:
STEPHANIE
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRIDGEMAN
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CCC-SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699031112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7830 SAGEMARK RIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CYPRESS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77433-4556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14255 CICERO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESTWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60445-2154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-371-0400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  146010926 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 235Z00000X , with the licence number: 105353 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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