Provider Demographics
NPI:1992211312
Name:HALL, STACIA
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACIA
Other - Middle Name:
Other - Last Name:PETTUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3613 WILLIAMS DR STE 406
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-1370
Mailing Address - Country:US
Mailing Address - Phone:512-864-0352
Mailing Address - Fax:512-864-3912
Practice Address - Street 1:103 CANAL LANDING BLVD STE 3
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-5108
Practice Address - Country:US
Practice Address - Phone:585-723-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14000052000237700000X
TX80928237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist