Healthcare Provider Details

I. General information

NPI: 1194493643
Provider Name (Legal Business Name): STEPHANIE ROBERTS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 W 16TH ST STE 3222
INDIANAPOLIS IN
46202-2207
US

IV. Provider business mailing address

355 W 16TH ST # 1078
INDIANAPOLIS IN
46202-2207
US

V. Phone/Fax

Practice location:
  • Phone: 317-963-7385
  • Fax:
Mailing address:
  • Phone: 317-963-7050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22002996A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: