Provider Demographics
NPI:1245383983
Name:COOPER LUCIDO, STACY L (MED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:COOPER LUCIDO
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-2319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 CUMMINGS CTR
Practice Address - Street 2:SUITE 3850
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6142
Practice Address - Country:US
Practice Address - Phone:978-232-0332
Practice Address - Fax:978-232-1103
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4438235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0709379Medicaid
MASP0184OtherBLUE CROSS