Provider Demographics
NPI:1659707990
Name:BLACK, STEPHANIE (SLP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HAMILTON POINTE DR
Mailing Address - Street 2:SUITE 115 & 120
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008
Mailing Address - Country:US
Mailing Address - Phone:478-538-1436
Mailing Address - Fax:478-474-6601
Practice Address - Street 1:100 HAMILTON POINTE DR
Practice Address - Street 2:115 & 120
Practice Address - City:BYRON
Practice Address - State:GA
Practice Address - Zip Code:31008
Practice Address - Country:US
Practice Address - Phone:478-538-1436
Practice Address - Fax:478-474-6601
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP12069775235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist