Healthcare Provider Details

I. General information

NPI: 1669628905
Provider Name (Legal Business Name): STEPHANIE J HERETH MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7594 CENTER RD.
WEST FALLS NY
14170-9644
US

IV. Provider business mailing address

7594 CENTER RD
WEST FALLS NY
14170-9644
US

V. Phone/Fax

Practice location:
  • Phone: 716-941-6148
  • Fax:
Mailing address:
  • Phone: 716-941-6148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number008656-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: