Provider Demographics
NPI:1376794040
Name:SANDERS, STEPHANIE L
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:SANDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 PROVIDENCE CIR
Mailing Address - Street 2:
Mailing Address - City:STATHAM
Mailing Address - State:GA
Mailing Address - Zip Code:30666-2132
Mailing Address - Country:US
Mailing Address - Phone:770-725-6213
Mailing Address - Fax:
Practice Address - Street 1:2981 HOG MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-1819
Practice Address - Country:US
Practice Address - Phone:706-769-0922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP 005910235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist