Provider Demographics
NPI:1023039906
Name:MATHIS, STACEY LEIGH (MS,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LEIGH
Last Name:MATHIS
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:LEIGH
Other - Last Name:MCKELROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5600 GOODMAN RD STE D
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7002
Mailing Address - Country:US
Mailing Address - Phone:662-895-4545
Mailing Address - Fax:662-895-4546
Practice Address - Street 1:5600 GOODMAN RD STE D
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7002
Practice Address - Country:US
Practice Address - Phone:662-895-4545
Practice Address - Fax:662-895-4546
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2304235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09877809Medicaid