Active NPI
Stephanie Rae Green
- Speech-Language Pathologist
- Mount Vernon, IL
National Provider Identifier
1447766290
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Speech-Language Pathologist
- License
- 146003822
- Practice address
- 401 N 30TH St
Mount Vernon, IL 62864-2355 - Phone
- (618) 244-8068
- Fax
- (618) 244-8075
- NPI assigned
- Dec 15, 2017
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Speech-Language Pathologist | 235Z00000X | 146003822 | IL | Primary |
Addresses
Primary practice location
401 N 30TH St
Mount Vernon, IL 62864-2355
Mailing address
14785 N Pump House LN
Mount Vernon, IL 62864-8750
Phone (618) 244-8068
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 363028 | Medicaid | IL |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 146003822 | IL | MD | Speech-Language Pathologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1513296000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1513296000000",
"number": "1447766290",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "14785 N PUMP HOUSE LN",
"city": "MOUNT VERNON",
"state": "IL",
"postal_code": "628648750",
"telephone_number": "618-244-8068",
"fax_number": "618-244-8075"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "401 N 30TH ST",
"city": "MOUNT VERNON",
"state": "IL",
"postal_code": "628642355",
"telephone_number": "618-244-8068",
"fax_number": "618-244-8075"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GREEN",
"first_name": "STEPHANIE",
"middle_name": "RAE",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2017-12-15",
"last_updated": "2017-12-15",
"status": "A"
},
"taxonomies": [
{
"code": "235Z00000X",
"taxonomy_group": "",
"desc": "Speech-Language Pathologist",
"state": "IL",
"license": "146003822",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "363028",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Mount Vernon, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 15, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.