Provider Demographics
NPI:1700193984
Name:PESA, SEPHANIE RACHEL (AUD)
Entity Type:Individual
Prefix:
First Name:SEPHANIE
Middle Name:RACHEL
Last Name:PESA
Suffix:
Gender:F
Credentials:AUD
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 1034
Mailing Address - Street 2:MAIL CODE P2AUD
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-1034
Mailing Address - Country:US
Mailing Address - Phone:630-913-1238
Mailing Address - Fax:
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:BLDG 100 ROOM 1D 103
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2964
Practice Address - Country:US
Practice Address - Phone:630-913-1238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2010-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147.001364231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist