Provider Demographics
NPI:1508140401
Name:STALLINGS, HEATHER (MCD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:STALLINGS
Suffix:
Gender:F
Credentials:MCD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:KETCHUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MCD
Mailing Address - Street 1:103 INTERCOM DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-2640
Mailing Address - Country:US
Mailing Address - Phone:256-464-9464
Mailing Address - Fax:256-325-9469
Practice Address - Street 1:103 INTERCOM DR
Practice Address - Street 2:SUITE C
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2640
Practice Address - Country:US
Practice Address - Phone:256-464-9464
Practice Address - Fax:256-325-9469
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET001675235Z00000X
GASLP007875235Z00000X
AL3454235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003126198AMedicaid