Provider Demographics
NPI:1659516524
Name:SANDERS, STACY L (AUD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:L
Last Name:SANDERS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LEANN
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5740 GETWELL RD. BUILDING 3 UNIT B
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672
Mailing Address - Country:US
Mailing Address - Phone:662-510-2138
Mailing Address - Fax:662-510-2962
Practice Address - Street 1:5740 GETWELL RD. BUILDING 3 UNIT B
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672
Practice Address - Country:US
Practice Address - Phone:662-510-2138
Practice Address - Fax:662-510-2962
Is Sole Proprietor?:No
Enumeration Date:2008-12-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA3297231H00000X
TNA0000001385231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07038576Medicaid