Provider Demographics
NPI:1821283763
Name:BREWER, STACI B (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:B
Last Name:BREWER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MS
Other - First Name:STACI
Other - Middle Name:B
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:360 WESTYN BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-5013
Mailing Address - Country:US
Mailing Address - Phone:407-913-1010
Mailing Address - Fax:407-992-8697
Practice Address - Street 1:1000 EMMETT ST STE 102
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-3605
Practice Address - Country:US
Practice Address - Phone:407-913-1010
Practice Address - Fax:407-992-8697
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA9608235Z00000X
FLSZ4300235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA9608OtherSTATE LICENSE
FLSZ4300Medicaid
FLSA9608OtherSTATE LICENSE