Provider Demographics
NPI:1861861460
Name:DISILET, STEPHANIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:DISILET
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 NECTARINE ST
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3027
Mailing Address - Country:US
Mailing Address - Phone:904-491-6660
Mailing Address - Fax:904-372-0496
Practice Address - Street 1:1595 LINKSIDE DR
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233-7308
Practice Address - Country:US
Practice Address - Phone:904-635-3179
Practice Address - Fax:904-372-0496
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-24
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13992235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist