Provider Demographics
NPI:1720544505
Name:SEBASTIAN, STACEY (SLPA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SEBASTIAN
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4563 E HEDGEHOG PL
Mailing Address - Street 2:
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-2688
Mailing Address - Country:US
Mailing Address - Phone:602-803-1693
Mailing Address - Fax:
Practice Address - Street 1:4563 E HEDGEHOG PL
Practice Address - Street 2:
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331-2688
Practice Address - Country:US
Practice Address - Phone:602-803-1693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-16
Last Update Date:2019-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA112652355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant