Provider Demographics
NPI:1275838310
Name:STACK, HEATHER (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:ORWIGSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17961-9623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 LAUREL RD
Practice Address - Street 2:
Practice Address - City:ORWIGSBURG
Practice Address - State:PA
Practice Address - Zip Code:17961-9623
Practice Address - Country:US
Practice Address - Phone:570-449-6174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL009891235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist