Provider Demographics
NPI:1003521659
Name:STEPHENSON, SUSAN A (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:STEPHENSON
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 1:502 WHEAT AVE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-4325
Mailing Address - Country:US
Mailing Address - Phone:229-246-4088
Mailing Address - Fax:229-246-0205
Practice Address - Street 1:502 WHEAT AVE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4325
Practice Address - Country:US
Practice Address - Phone:229-246-4088
Practice Address - Fax:229-246-0205
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPECT003772235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58-2082439OtherTAX ID