Provider Demographics
NPI:1619622859
Name:FAME SPEECH AND MYO
Entity Type:Organization
Organization Name:FAME SPEECH AND MYO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ALEXA
Authorized Official - Middle Name:
Authorized Official - Last Name:STUBENRAUCH
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:717-875-0962
Mailing Address - Street 1:178 VISTA GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-1754
Mailing Address - Country:US
Mailing Address - Phone:717-875-0962
Mailing Address - Fax:
Practice Address - Street 1:13490 GRAN BAY PKWY APT 732
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-7439
Practice Address - Country:US
Practice Address - Phone:717-875-0962
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-16
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty