Provider Demographics
NPI:1629396312
Name:STEVENSON, DANA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 GINKGO LN
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5392
Mailing Address - Country:US
Mailing Address - Phone:803-271-2852
Mailing Address - Fax:
Practice Address - Street 1:536 GRAND SLAM DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-8044
Practice Address - Country:US
Practice Address - Phone:706-854-8434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-05
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4450235Z00000X
GASLP007503235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist