Provider Demographics
NPI:1821396094
Name:THOMAS, STACIA L (AUD)
Entity Type:Individual
Prefix:DR
First Name:STACIA
Middle Name:L
Last Name:THOMAS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:STACIA
Other - Middle Name:
Other - Last Name:BARBOZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:1250 FOREST AVE
Practice Address - Street 2:STE 301
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1889
Practice Address - Country:US
Practice Address - Phone:207-797-5753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-11
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP2351231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003479200Medicaid
MEE400160375OtherMEDICARE PTAN
MEE400159752OtherMEDICARE PTAN