Provider Demographics
NPI:1164683504
Name:KINDERVATER, STACY ANN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:ANN
Last Name:KINDERVATER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MRS
Other - First Name:STACY
Other - Middle Name:ANN
Other - Last Name:BURRALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:810 W MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72201-1306
Mailing Address - Country:US
Mailing Address - Phone:501-447-1000
Mailing Address - Fax:501-447-4801
Practice Address - Street 1:1200 RESERVOIR RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72227-5712
Practice Address - Country:US
Practice Address - Phone:501-447-5529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP1123235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116837743Medicaid