Provider Demographics
NPI:1235490517
Name:CHURCH, STACY B (MCD CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:B
Last Name:CHURCH
Suffix:
Gender:F
Credentials:MCD CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CEDARBROOK LN
Mailing Address - Street 2:
Mailing Address - City:KILLEN
Mailing Address - State:AL
Mailing Address - Zip Code:35645-6867
Mailing Address - Country:US
Mailing Address - Phone:334-618-4453
Mailing Address - Fax:
Practice Address - Street 1:100 SCHOOL LN
Practice Address - Street 2:
Practice Address - City:KILLEN
Practice Address - State:AL
Practice Address - Zip Code:35645-9054
Practice Address - Country:US
Practice Address - Phone:256-757-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist