Healthcare Provider Details

I. General information

NPI: 1174684591
Provider Name (Legal Business Name): SPEECH PATHOLOGY AND AUDIOLOGY SERVICES OF ROBESON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 OAKRIDGE BLVD
LUMBERTON NC
28358-2325
US

IV. Provider business mailing address

765 OAKRIDGE BLVD
LUMBERTON NC
28358-2325
US

V. Phone/Fax

Practice location:
  • Phone: 910-738-6071
  • Fax: 910-738-3002
Mailing address:
  • Phone: 910-738-6071
  • Fax: 910-738-3002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5408
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENNIFER INMAN STEPHENSON
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: M.S. CCC-SLP
Phone: 910-738-6071