Provider Demographics
NPI:1073135885
Name:EDGAR, STACEY (SLS)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:EDGAR
Suffix:
Gender:F
Credentials:SLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 HECKER ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-3975
Mailing Address - Country:US
Mailing Address - Phone:603-624-3600
Mailing Address - Fax:
Practice Address - Street 1:112 RESERVOIR AVE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-4468
Practice Address - Country:US
Practice Address - Phone:603-624-6352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH71891235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist