Provider Demographics
NPI:1639288616
Name:STAVROPULOS, TIMOTHY GEORGE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:GEORGE
Last Name:STAVROPULOS
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2152
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-2152
Mailing Address - Country:US
Mailing Address - Phone:904-471-0293
Mailing Address - Fax:904-346-5111
Practice Address - Street 1:4600 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-4764
Practice Address - Country:US
Practice Address - Phone:904-346-5100
Practice Address - Fax:904-343-6511
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLSA 000496235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist