Provider Demographics
NPI:1447766290
Name:GREEN, STEPHANIE RAE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RAE
Last Name:GREEN
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 1:14785 N PUMP HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-8750
Mailing Address - Country:US
Mailing Address - Phone:618-244-8068
Mailing Address - Fax:618-244-8075
Practice Address - Street 1:401 N 30TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2355
Practice Address - Country:US
Practice Address - Phone:618-244-8068
Practice Address - Fax:618-244-8075
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146003822235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363028Medicaid