Provider Demographics
NPI:1063684140
Name:SHILTS, STACEY LEE (MS CCC-A)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LEE
Last Name:SHILTS
Suffix:
Gender:F
Credentials:MS CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MICHIGAN AVE
Mailing Address - Street 2:STE 215
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1594
Mailing Address - Country:US
Mailing Address - Phone:574-753-2222
Mailing Address - Fax:574-753-0522
Practice Address - Street 1:1025 MICHIGAN AVE
Practice Address - Street 2:STE 215
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1594
Practice Address - Country:US
Practice Address - Phone:574-753-2222
Practice Address - Fax:574-753-0522
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002220A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist