Provider Demographics
NPI:1346308269
Name:DENNARD, STACEY S (SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:S
Last Name:DENNARD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 FIRST ST
Mailing Address - Street 2:
Mailing Address - City:CADDO MILLS
Mailing Address - State:TX
Mailing Address - Zip Code:75135-6822
Mailing Address - Country:US
Mailing Address - Phone:903-527-8115
Mailing Address - Fax:
Practice Address - Street 1:2505 FIRST ST
Practice Address - Street 2:
Practice Address - City:CADDO MILLS
Practice Address - State:TX
Practice Address - Zip Code:75135-6822
Practice Address - Country:US
Practice Address - Phone:903-527-8115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14892235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA023OtherTRICARE NUMBER
TX005783802Medicaid