Basic Information
| Provider Information | |||||||||
| NPI: | 1285759167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENSON | ||||||||
| FirstName: | MARLAINA | ||||||||
| MiddleName: | RAYE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 MAPLETOWN RD | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153381001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249433677 | ||||||||
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| Practice Location | |||||||||
| Address1: | 161 BAKERS RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265081459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042850692 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 05/20/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 05368 | MD | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SLP-1062 | WV | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 49303 | 01 | VITAL STIM | OTHER | 12078256 | 01 | NOMS | OTHER |