Provider Demographics
NPI:1578609111
Name:PARDUE, STACIE L (MA)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:L
Last Name:PARDUE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4016 CORTEZ RD W
Mailing Address - Street 2:SUITE 1105
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-3110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4440B 26TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-1201
Practice Address - Country:US
Practice Address - Phone:941-752-0408
Practice Address - Fax:941-870-0876
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007210235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890256900Medicaid