Healthcare Provider Details

I. General information

NPI: 1639288616
Provider Name (Legal Business Name): TIMOTHY GEORGE STAVROPULOS M.A., CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 BEACH BLVD
JACKSONVILLE FL
32207-4764
US

IV. Provider business mailing address

PO BOX 2152
SAINT AUGUSTINE FL
32085-2152
US

V. Phone/Fax

Practice location:
  • Phone: 904-346-5100
  • Fax: 904-343-6511
Mailing address:
  • Phone: 904-471-0293
  • Fax: 904-346-5111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA 000496
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: