Provider Demographics
NPI:1942855796
Name:STEWART, STEPHANIE WHILDEN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:WHILDEN
Last Name:STEWART
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 1:1107 GREER ST
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-1920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1107 GREER ST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-1920
Practice Address - Country:US
Practice Address - Phone:273-229-9445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GAPCET002993235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program