Provider Demographics
NPI:1851623748
Name:HUTTMAN, STACY ILYSE (MS, CCC -SLP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ILYSE
Last Name:HUTTMAN
Suffix:
Gender:F
Credentials:MS, CCC -SLP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:ILYSE
Other - Last Name:DERSHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:19312 SKYRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33498-6212
Mailing Address - Country:US
Mailing Address - Phone:561-852-7752
Mailing Address - Fax:
Practice Address - Street 1:19312 SKYRIDGE CIR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33498-6212
Practice Address - Country:US
Practice Address - Phone:561-852-7752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6532235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist