Provider Demographics
NPI:1841600459
Name:DEITRICK, STACY L (MACCCSLP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:DEITRICK
Suffix:
Gender:F
Credentials:MACCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 SILVER PALM DR APT 203
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34747-2746
Mailing Address - Country:US
Mailing Address - Phone:937-733-6216
Mailing Address - Fax:
Practice Address - Street 1:1201 DALY DR
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:IN
Practice Address - Zip Code:46774-1891
Practice Address - Country:US
Practice Address - Phone:260-749-0413
Practice Address - Fax:260-749-2531
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA19289235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist