Healthcare Provider Details

I. General information

NPI: 1861861460
Provider Name (Legal Business Name): STEPHANIE DESILET MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2015
Last Update Date: 07/21/2024
Certification Date: 07/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 INDIGO ST
FERNANDINA BEACH FL
32034-3763
US

IV. Provider business mailing address

1463 NECTARINE ST
FERNANDINA BEACH FL
32034-3027
US

V. Phone/Fax

Practice location:
  • Phone: 904-635-3179
  • Fax: 904-372-0496
Mailing address:
  • Phone: 904-491-6660
  • Fax: 904-372-0496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA13992
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: