Healthcare Provider Details

I. General information

NPI: 1629507272
Provider Name (Legal Business Name): STEPHANIE ROSE CENTERA SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE ROSE SANTOS SLPA

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 N. LAKE HAVASU AVE. STE #100
LAKE HAVASU CITY AZ
86404
US

IV. Provider business mailing address

1515 N. LAKE HAVASU AVE STE #100
LAKE HAVASU CITY AZ
86404
US

V. Phone/Fax

Practice location:
  • Phone: 928-854-5439
  • Fax: 928-854-5440
Mailing address:
  • Phone: 928-854-5439
  • Fax: 928-854-5440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA10564
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP10564
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: