Provider Demographics
NPI:1336314814
Name:LONG, STEPHANIE ROBERTS (AUD DOCTOR AUDILOGY)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ROBERTS
Last Name:LONG
Suffix:
Gender:F
Credentials:AUD DOCTOR AUDILOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W3124 VAN ROY RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-3982
Mailing Address - Country:US
Mailing Address - Phone:920-915-9077
Mailing Address - Fax:
Practice Address - Street 1:W3124 VAN ROY RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-3982
Practice Address - Country:US
Practice Address - Phone:920-915-9077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI232-156231H00000X, 231HA2400X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41128700Medicaid