Provider Demographics
NPI:1194864249
Name:AULTMAN, STEPHANIE MACHELLE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MACHELLE
Last Name:AULTMAN
Suffix:
Gender:F
Credentials:MS 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:PO BOX 49
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-0049
Mailing Address - Country:US
Mailing Address - Phone:601-270-6968
Mailing Address - Fax:
Practice Address - Street 1:100 W FRONT ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-3460
Practice Address - Country:US
Practice Address - Phone:601-270-6968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2122235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122690Medicaid