Provider Demographics
NPI:1356653562
Name:SAND, STACEY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SAND
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 1:562 W END AVE APT 4C
Mailing Address - Street 2:4C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-2747
Mailing Address - Country:US
Mailing Address - Phone:212-674-8566
Mailing Address - Fax:
Practice Address - Street 1:562 W END AVE APT 4C
Practice Address - Street 2:APT 4C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-2747
Practice Address - Country:US
Practice Address - Phone:212-674-8566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013603-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist