Provider Demographics
NPI:1790336766
Name:HARRIS, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 WILLOW CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:GA
Mailing Address - Zip Code:30179-3972
Mailing Address - Country:US
Mailing Address - Phone:678-988-0772
Mailing Address - Fax:
Practice Address - Street 1:514 WILLOW CREEK DR
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:GA
Practice Address - Zip Code:30179-3972
Practice Address - Country:US
Practice Address - Phone:678-988-0772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-21
Last Update Date:2019-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist