Provider Demographics
NPI:1992119788
Name:LARAQUE, STEPHANIE (MS)
Entity type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:
Last Name:LARAQUE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1158 45TH ST
Mailing Address - Street 2:BROOKLYN
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2059
Mailing Address - Country:US
Mailing Address - Phone:718-480-5569
Mailing Address - Fax:
Practice Address - Street 1:1158 45TH ST
Practice Address - Street 2:BROOKLYN
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2059
Practice Address - Country:US
Practice Address - Phone:718-480-5569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY024099-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program