Provider Demographics
NPI:1518220177
Name:STUCKEY, MOLLY BRYN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:BRYN
Last Name:STUCKEY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 DOVE ST STE 150
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2837
Mailing Address - Country:US
Mailing Address - Phone:949-630-8290
Mailing Address - Fax:949-396-1242
Practice Address - Street 1:1151 DOVE ST STE 150
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2837
Practice Address - Country:US
Practice Address - Phone:949-630-8290
Practice Address - Fax:949-396-1242
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14040235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ50907ZOtherANTHEM BLUE CROSS OF CA