Provider Demographics
NPI:1376093740
Name:FAHEY, STEPHANIE NICOLE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:FAHEY
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 1:5220 S 6TH STREET RD
Mailing Address - Street 2:SUITE 1700 (NOLL MEDICAL PAVILLION, THE AUTISM CLINIC)
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-5735
Mailing Address - Country:US
Mailing Address - Phone:217-525-8332
Mailing Address - Fax:
Practice Address - Street 1:5220 S 6TH STREET RD
Practice Address - Street 2:SUITE 1700 (NOLL MEDICAL PAVILLION, THE AUTISM CLINIC)
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5735
Practice Address - Country:US
Practice Address - Phone:217-525-8332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011697235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist