Provider Demographics
NPI:1013780311
Name:STOVALL, INGERBENEDIKTE (MA, CCC-SLP; BCTMB)
Entity Type:Individual
Prefix:
First Name:INGERBENEDIKTE
Middle Name:
Last Name:STOVALL
Suffix:
Gender:F
Credentials:MA, CCC-SLP; BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1177
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34133-1177
Mailing Address - Country:US
Mailing Address - Phone:941-928-8146
Mailing Address - Fax:
Practice Address - Street 1:27300 RIVERVIEW CENTER BLVD STE 101
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4316
Practice Address - Country:US
Practice Address - Phone:941-928-8146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1109235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist