Provider Demographics
NPI:1619269453
Name:BACON, TRISHA ANN (SLP)
Entity Type:Individual
Prefix:MRS
First Name:TRISHA
Middle Name:ANN
Last Name:BACON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MS
Other - First Name:TRISHA
Other - Middle Name:ANN
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1295 LEXINGTON SQ SW
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32962-3410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6011 SE TOWER DR
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-7615
Practice Address - Country:US
Practice Address - Phone:315-532-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist