Provider Demographics
NPI:1033369418
Name:MECHAM, STACEY (SLP)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:MECHAM
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MRS
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:HYDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 262
Mailing Address - Street 2:
Mailing Address - City:CAREY
Mailing Address - State:ID
Mailing Address - Zip Code:83320-0262
Mailing Address - Country:US
Mailing Address - Phone:208-721-0086
Mailing Address - Fax:
Practice Address - Street 1:120 LITTLE WOOD RIVER RD.
Practice Address - Street 2:
Practice Address - City:CAREY
Practice Address - State:ID
Practice Address - Zip Code:83320-0262
Practice Address - Country:US
Practice Address - Phone:208-721-0086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1432235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist