Provider Demographics
NPI:1265615520
Name:RODEGHERO, CHANCY NICOLE
Entity type:Individual
Prefix:MS
First Name:CHANCY
Middle Name:NICOLE
Last Name:RODEGHERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10960 SCOTT PL
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-7387
Mailing Address - Country:US
Mailing Address - Phone:573-822-5732
Mailing Address - Fax:
Practice Address - Street 1:1416 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4261
Practice Address - Country:US
Practice Address - Phone:217-223-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006015397235Z00000X
IL146012060235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO467618906Medicaid