Provider Demographics
NPI:1386015063
Name:BERNAL, STACEY JUSTINE (MA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:JUSTINE
Last Name:BERNAL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 FORTINO BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2086
Mailing Address - Country:US
Mailing Address - Phone:719-305-8313
Mailing Address - Fax:
Practice Address - Street 1:704 FORTINO BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2086
Practice Address - Country:US
Practice Address - Phone:719-305-8313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0001282235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist