Provider Demographics
NPI:1770863771
Name:MARTIN, STACEY MARIE
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:MARIE
Other - Last Name:MELBYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1736 MIDDLETON AVENUE
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532
Mailing Address - Country:US
Mailing Address - Phone:630-493-8076
Mailing Address - Fax:630-971-4069
Practice Address - Street 1:1736 MIDDLETON AVENUE
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532
Practice Address - Country:US
Practice Address - Phone:630-493-8076
Practice Address - Fax:630-971-4069
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2022-07-21
Deactivation Date:2014-07-08
Deactivation Code:
Reactivation Date:2018-01-29
Provider Licenses
StateLicense IDTaxonomies
IL146011200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist