Provider Demographics
NPI:1629507272
Name:CENTERA, STEPHANIE ROSE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ROSE
Last Name:CENTERA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:ROSE
Other - Last Name:SANTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLPA
Mailing Address - Street 1:1515 N. LAKE HAVASU AVE
Mailing Address - Street 2:STE #100
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404
Mailing Address - Country:US
Mailing Address - Phone:928-854-5439
Mailing Address - Fax:928-854-5440
Practice Address - Street 1:1515 N. LAKE HAVASU AVE.
Practice Address - Street 2:STE #100
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86404
Practice Address - Country:US
Practice Address - Phone:928-854-5439
Practice Address - Fax:928-854-5440
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP10564235Z00000X
AZSLPA105642355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ274297Medicaid