Provider Demographics
NPI:1538378104
Name:MATLOCK, STEPHANIE L (AUD, CCC-A)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:L
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 ENGLISH OAK CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-8421
Mailing Address - Country:US
Mailing Address - Phone:252-847-5436
Mailing Address - Fax:252-847-1301
Practice Address - Street 1:2100 STANTONSBURG
Practice Address - Street 2:VIDANT MEDICAL SYSTEM AUDIOLOGY
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834
Practice Address - Country:US
Practice Address - Phone:252-847-5436
Practice Address - Fax:252-847-1301
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6550231H00000X
NC1143237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6550OtherAUDIOLOGIST
12026680OtherASHA CERTIFICATE
NC6550OtherAUDIOLOGIST