Provider Demographics
NPI:1477841542
Name:VANBODEGON, STACIE L (AUD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:L
Last Name:VANBODEGON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 OLD NEWPORT BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4234
Mailing Address - Country:US
Mailing Address - Phone:949-642-7935
Mailing Address - Fax:949-642-2950
Practice Address - Street 1:500 OLD NEWPORT BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4234
Practice Address - Country:US
Practice Address - Phone:949-642-7935
Practice Address - Fax:949-642-2950
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist