Provider Demographics
NPI:1417183062
Name:CANTRELL, STACEY LYNN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:200 CRIGHTON RDG
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-6348
Mailing Address - Country:US
Mailing Address - Phone:318-773-5719
Mailing Address - Fax:318-425-3236
Practice Address - Street 1:200 CRIGHTON RDG
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-6348
Practice Address - Country:US
Practice Address - Phone:318-773-5719
Practice Address - Fax:318-425-3236
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5522235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist