Provider Demographics
NPI:1407414287
Name:DISTELRATH, STEPHANIE GRACE (SLPA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:GRACE
Last Name:DISTELRATH
Suffix:
Gender:F
Credentials:SLPA
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 1817
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91785-1817
Mailing Address - Country:US
Mailing Address - Phone:909-331-7693
Mailing Address - Fax:
Practice Address - Street 1:410 E MERCED AVE STE E
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-5058
Practice Address - Country:US
Practice Address - Phone:909-331-7693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14472355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant