Provider Demographics
NPI:1043887771
Name:CARROTHERS, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:CARROTHERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 11TH AVE S STE 155
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3918
Mailing Address - Country:US
Mailing Address - Phone:208-466-1077
Mailing Address - Fax:
Practice Address - Street 1:101 11TH AVE S STE 155
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3918
Practice Address - Country:US
Practice Address - Phone:208-466-1077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-4777235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist