Provider Demographics
NPI:1770847501
Name:ROTHENBERGER, STACY CHANTEL (MS CCC-SLP, CLC)
Entity Type:Individual
Prefix:MISS
First Name:STACY
Middle Name:CHANTEL
Last Name:ROTHENBERGER
Suffix:
Gender:F
Credentials:MS CCC-SLP, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 ROCKRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7970
Mailing Address - Country:US
Mailing Address - Phone:803-520-4091
Mailing Address - Fax:
Practice Address - Street 1:112 ROCKRIDGE CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7970
Practice Address - Country:US
Practice Address - Phone:803-520-4091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC253737235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist