Provider Demographics
NPI:1417297805
Name:SUPER, STEPHANIE PADGETT
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:PADGETT
Last Name:SUPER
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 1:3124 MEADOWVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-8779
Mailing Address - Country:US
Mailing Address - Phone:270-668-7306
Mailing Address - Fax:
Practice Address - Street 1:3124 MEADOWVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-8779
Practice Address - Country:US
Practice Address - Phone:270-668-7306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY143067235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist