Provider Demographics
NPI:1881722627
Name:THERIOT, STEPHANIE M (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:M
Last Name:THERIOT
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W CANAL ST
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3916
Mailing Address - Country:US
Mailing Address - Phone:601-889-9800
Mailing Address - Fax:601-889-9885
Practice Address - Street 1:621 W CANAL ST
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3916
Practice Address - Country:US
Practice Address - Phone:601-889-9800
Practice Address - Fax:601-889-9885
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3081235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02020221Medicaid