Provider Demographics
NPI:1902223316
Name:BRANSON, STACEY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BRANSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 N. JACKSON STREET
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388
Mailing Address - Country:US
Mailing Address - Phone:931-455-5189
Mailing Address - Fax:931-393-2455
Practice Address - Street 1:2110 N. JACKSON STREET
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388
Practice Address - Country:US
Practice Address - Phone:931-455-5189
Practice Address - Fax:931-393-2455
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP4757235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist