Provider Demographics
NPI:1801533211
Name:FUQUA, STEPHANIE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:FUQUA
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 1:500 W LYNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:TX
Mailing Address - Zip Code:76706-5505
Mailing Address - Country:US
Mailing Address - Phone:972-795-1315
Mailing Address - Fax:
Practice Address - Street 1:500 W LYNDALE AVE
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:TX
Practice Address - Zip Code:76706-5505
Practice Address - Country:US
Practice Address - Phone:254-662-0194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110245235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist