Provider Demographics
NPI:1689137101
Name:STEPHENS, CARSON
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 WHITE WING DOVE PL
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-2920
Mailing Address - Country:US
Mailing Address - Phone:904-439-0003
Mailing Address - Fax:
Practice Address - Street 1:1851 GOLDEN EAGLE WAY STE 43
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4334
Practice Address - Country:US
Practice Address - Phone:904-374-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI36262355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSI3626OtherSPEECH LANGUAGE PATHOLOGIST ASSISTANT LICENSURE