Provider Demographics
NPI:1467755595
Name:WHITE, STACEY LYNN (SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:WHITE
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 1:10767 TEA OLIVE LN
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33498-4844
Mailing Address - Country:US
Mailing Address - Phone:954-249-4585
Mailing Address - Fax:
Practice Address - Street 1:10767 TEA OLIVE LN
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33498-4844
Practice Address - Country:US
Practice Address - Phone:954-249-4585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-12
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10099235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist