Provider Demographics
NPI:1053718122
Name:KOLACH, STEPHANIE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:KOLACH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3680 SELMA RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502-6310
Mailing Address - Country:US
Mailing Address - Phone:937-328-5378
Mailing Address - Fax:
Practice Address - Street 1:3640 E HIGH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-1645
Practice Address - Country:US
Practice Address - Phone:937-328-5380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11364235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist