Provider Demographics
NPI:1093919433
Name:STEPHAN, MARY PATRICIA (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:PATRICIA
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4631 NW 53RD AVENUE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608
Mailing Address - Country:US
Mailing Address - Phone:352-373-5389
Mailing Address - Fax:352-376-5290
Practice Address - Street 1:4631 NW 53RD AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-4357
Practice Address - Country:US
Practice Address - Phone:352-373-5389
Practice Address - Fax:352-376-5290
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA112235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist