Provider Demographics
NPI:1588857023
Name:FORD-BURLESON, STACIE LYNN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LYNN
Last Name:FORD-BURLESON
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 1:448 SW THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-4559
Mailing Address - Country:US
Mailing Address - Phone:817-832-9594
Mailing Address - Fax:
Practice Address - Street 1:448 SW THOMAS ST
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-4559
Practice Address - Country:US
Practice Address - Phone:817-832-9594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17379235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist