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General NPI Number Information
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NPI Number | 1619622859
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Entity Type | Organization
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Legal Business Name | FAME SPEECH AND MYO
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Dates
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Enumeration Date | 02/16/2022
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Last Update Date | 11/04/2022
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Provider Practice Location Address
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Address Line | 13490 GRAN BAY PKWY APT 732
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City | JACKSONVILLE
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State | FL
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Zip | 32258-7439
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Country | US
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Telephone | 717-875-0962
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Fax |
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Provider Business Mailing Address
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Address Line | 178 VISTA GRANDE DR
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082-1754
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Country | US
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Telephone | 717-875-0962
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Fax |
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Authorized Official
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Title or Position | SPEECH LANGUAGE PATHOLOGIST
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Name | ALEXA STUBENRAUCH
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Credential | MS CCC-SLP
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Telephone | 717-875-0962
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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