Provider Demographics
NPI:1629692629
Name:LOOSE, STACEY ANNE (MA CF-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:ANNE
Last Name:LOOSE
Suffix:
Gender:F
Credentials:MA CF-SLP
Other - Prefix:MISS
Other - First Name:STACEY
Other - Middle Name:ANNE
Other - Last Name:BURROWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5980 HIGHWAY 54 S UNIT 3334
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88311-9506
Mailing Address - Country:US
Mailing Address - Phone:575-921-2408
Mailing Address - Fax:
Practice Address - Street 1:1451 GALWAY DR
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-7845
Practice Address - Country:US
Practice Address - Phone:575-495-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist