Provider Demographics
NPI:1437219342
Name:JOLLY-LASSITER, STACEY MAE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MAE
Last Name:JOLLY-LASSITER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8805 BOARS HEAD CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-1202
Mailing Address - Country:US
Mailing Address - Phone:919-649-4690
Mailing Address - Fax:919-510-0070
Practice Address - Street 1:4020 BARRETT DR
Practice Address - Street 2:SUITE 205
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6624
Practice Address - Country:US
Practice Address - Phone:919-787-4400
Practice Address - Fax:919-510-0070
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5790235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411864Medicaid