Provider Demographics
NPI:1275893489
Name:NEFFENDORF, STACIE LYNN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LYNN
Last Name:NEFFENDORF
Suffix:
Gender:F
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:PO BOX 65571
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79464-5571
Mailing Address - Country:US
Mailing Address - Phone:806-445-2899
Mailing Address - Fax:806-370-5817
Practice Address - Street 1:3417 73RD ST STE N
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423
Practice Address - Country:US
Practice Address - Phone:806-445-2899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-22
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106088235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164901Medicaid
TX1275893489OtherBLUE CROSS BLUE SHIELD OF TEXAS
TX149984001Medicaid
TX456606Medicare PIN