Provider Demographics
NPI:1891223335
Name:THORN, STACEY (MS SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:THORN
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17212 N SCOTTSDALE RD APT 2083
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-9629
Mailing Address - Country:US
Mailing Address - Phone:262-422-9074
Mailing Address - Fax:
Practice Address - Street 1:16815 S DESERT FOOTHILLS PKWY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-8401
Practice Address - Country:US
Practice Address - Phone:480-704-5954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-29
Last Update Date:2017-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP10580235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist