Provider Demographics
NPI:1376657114
Name:WALLEN, STACEY (PH D, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WALLEN
Suffix:
Gender:F
Credentials:PH D, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 DISCOVERY CIR W
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-1006
Mailing Address - Country:US
Mailing Address - Phone:954-415-4069
Mailing Address - Fax:954-596-0355
Practice Address - Street 1:3201 ROCKPORT DR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-1834
Practice Address - Country:US
Practice Address - Phone:954-415-4069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5662235Z00000X
GASLP006932235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASLP006932OtherGA LICENSE NUMBER
FLSA5662OtherSTATE LICENSE NUMBER
GA003121866BMedicaid
FL8857075Medicaid