Provider Demographics
NPI:1285044701
Name:DURHAM, STEPHANIE (SLP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:DURHAM
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DESIARD ST
Mailing Address - Street 2:SUITE 355
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7319
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-6603
Practice Address - Street 1:1325 LOUISVILLE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6021
Practice Address - Country:US
Practice Address - Phone:318-807-1500
Practice Address - Fax:318-807-1504
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6088235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2367722Medicaid
LA2367722Medicaid