Provider Demographics
NPI:1093337230
Name:HARRIS, STACEY KELEEN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:KELEEN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 DIXON AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8722
Mailing Address - Country:US
Mailing Address - Phone:406-304-8330
Mailing Address - Fax:406-303-4016
Practice Address - Street 1:208 DIXON AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8722
Practice Address - Country:US
Practice Address - Phone:406-304-8330
Practice Address - Fax:406-303-4016
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-LIC-9724235Z00000X
MTMT-SLP-SP-LIC-9724235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist