Provider Demographics
NPI:1033399829
Name:PENNELL, STACEY (SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:PENNELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2370 MINERAL CITY ZOAR RD NE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:OH
Mailing Address - Zip Code:44612-8502
Mailing Address - Country:US
Mailing Address - Phone:330-575-3546
Mailing Address - Fax:
Practice Address - Street 1:540 HIGH ST NW
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:44615-1116
Practice Address - Country:US
Practice Address - Phone:330-627-5524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSLP 8244235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist