Provider Demographics
NPI:1093105280
Name:STACY O'BRIEN AUDIOLOGY
Entity Type:Organization
Organization Name:STACY O'BRIEN AUDIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:A
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:813-767-0938
Mailing Address - Street 1:4624 RIVERWALK VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:PONCE INLET
Mailing Address - State:FL
Mailing Address - Zip Code:32127-7261
Mailing Address - Country:US
Mailing Address - Phone:813-767-0938
Mailing Address - Fax:
Practice Address - Street 1:1185 DUNLAWTON AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-2905
Practice Address - Country:US
Practice Address - Phone:813-767-0938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL14000162663231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty