Provider Demographics
NPI:1659672392
Name:STALEY, ROLANDA O (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ROLANDA
Middle Name:O
Last Name:STALEY
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 WILLOW FORKS RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29073-7202
Mailing Address - Country:US
Mailing Address - Phone:803-640-0548
Mailing Address - Fax:
Practice Address - Street 1:1354 CONGRESS DR NW
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-3128
Practice Address - Country:US
Practice Address - Phone:803-648-2268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-11
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3697235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist