Provider Demographics
NPI:1659628931
Name:BAKEWELL, STEPHANIE L (AUDIOLOGIST)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:BAKEWELL
Suffix:
Gender:F
Credentials:AUDIOLOGIST
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:WOODRUFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:249 SMITH RD
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:THOMASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06787-1234
Mailing Address - Country:US
Mailing Address - Phone:203-228-6380
Mailing Address - Fax:203-264-8201
Practice Address - Street 1:2 POMPERAUG OFFICE PARK
Practice Address - Street 2:SUITE 307
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488
Practice Address - Country:US
Practice Address - Phone:203-264-8201
Practice Address - Fax:203-264-8201
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT523231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1659628931Medicaid