Provider Demographics
NPI:1407384472
Name:ROBERSON, STACIE WENDEL (SLP)
Entity Type:Individual
Prefix:MS
First Name:STACIE
Middle Name:WENDEL
Last Name:ROBERSON
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 1:613 WINTERIDGE PL
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4144
Mailing Address - Country:US
Mailing Address - Phone:601-720-1878
Mailing Address - Fax:
Practice Address - Street 1:1417 LELIA DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4721
Practice Address - Country:US
Practice Address - Phone:601-982-7827
Practice Address - Fax:601-982-0080
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-02
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS4008235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist