Provider Demographics
NPI:1407027899
Name:IHLE, STACEY ANN (MA,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:IHLE
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ANN
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA,CCC-SLP
Mailing Address - Street 1:825 1ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-6846
Mailing Address - Country:US
Mailing Address - Phone:651-633-7875
Mailing Address - Fax:651-628-9335
Practice Address - Street 1:825 1ST AVE NW
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-6846
Practice Address - Country:US
Practice Address - Phone:651-633-7875
Practice Address - Fax:651-628-9335
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7907235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist