Provider Demographics
NPI:1275082802
Name:STOCKDALE, TIMOTHY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:STOCKDALE
Suffix:
Gender:M
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 1:14502 N DALE MABRY HWY STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2040
Mailing Address - Country:US
Mailing Address - Phone:813-812-4463
Mailing Address - Fax:
Practice Address - Street 1:14502 N DALE MABRY HWY STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2040
Practice Address - Country:US
Practice Address - Phone:813-812-4463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 14171235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018980200Medicaid
FL4TM44OtherBLUE CROSS BLUE SHIELD
FL018980200Medicaid