Provider Demographics
NPI:1336551977
Name:MITCHELL DESPAIN, STEPHANIE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MITCHELL DESPAIN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 S WHEELER ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-4540
Mailing Address - Country:US
Mailing Address - Phone:409-202-5002
Mailing Address - Fax:844-848-9342
Practice Address - Street 1:526 S WHEELER ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4540
Practice Address - Country:US
Practice Address - Phone:409-202-5002
Practice Address - Fax:844-848-9342
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109960235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist