Provider Demographics
NPI:1760798532
Name:SHEA, STACEY M (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:SHEA
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 1:12 MARIAN LN
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-1840
Mailing Address - Country:US
Mailing Address - Phone:516-376-2746
Mailing Address - Fax:
Practice Address - Street 1:311 E 82ND ST
Practice Address - Street 2:MANHATTAN NEW SCHOOL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-4103
Practice Address - Country:US
Practice Address - Phone:212-734-7127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
NY021313235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist