Basic Information
| Provider Information | |||||||||
| NPI: | 1265822837 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANSOEST | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CCC- SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OBERT | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CF-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 468 | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049760468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078588353 | ||||||||
| FaxNumber: | 2074749261 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 FAIRVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049761481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074747000 | ||||||||
| FaxNumber: | 2078584772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2015 | ||||||||
| LastUpdateDate: | 06/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP2768 | ME | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 1265822837 | 05 | ME | MEDICAID |