Provider Demographics
NPI:1477186310
Name:LANG, STACEY NICOLE (SPEECH PATHOLOGIST)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:NICOLE
Last Name:LANG
Suffix:
Gender:F
Credentials:SPEECH PATHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8477 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5028
Mailing Address - Country:US
Mailing Address - Phone:352-382-7214
Mailing Address - Fax:352-382-7781
Practice Address - Street 1:1100 S COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3804
Practice Address - Country:US
Practice Address - Phone:321-452-1233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA9346235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist