Provider Demographics
NPI:1790939353
Name:GRANT, STEPHANIE Q (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:Q
Last Name:GRANT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 BLACKHAWK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-1115
Mailing Address - Country:US
Mailing Address - Phone:717-449-1389
Mailing Address - Fax:
Practice Address - Street 1:5012 BLACKHAWK DR
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-1115
Practice Address - Country:US
Practice Address - Phone:717-449-1389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#2526235Z00000X
FLSA 11094235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist