MEDICARE: MRS. STEPHANIE WIGHTMAN M.A., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SP.14638	OH
2	2255A2300X	Athletic Trainer	COND.20201555-SP	OH
3	235Z00000X	Speech-Language Pathologist	SLP-SP-LIC-11420	MT

General Provider Information

NPI Number	:	1497355085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STEPHANIE WIGHTMAN M.A., CCC-SLP

Provider Business Mailing Address
First Line	:	208 CIDER MILL LN
Second Line	:
City	:	BRUNSWICK
State	:	OH
Zip	:	44212-1539
Country	:	US
Telephone Number	:	440-591-8642
Fax Number	:

Provider Business Practice Location Address
First Line	:	1655 SHILOH RD STE D
Second Line	:
City	:	BILLINGS
State	:	MT
Zip	:	59106-1726
Country	:	US
Telephone Number	:	406-629-1175
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2020
Last Update Date	:	02/27/2023

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