Provider Demographics
NPI:1013246859
Name:CANNON, STACEY (SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 EARL GARRETT ST STE 108
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-4500
Mailing Address - Country:US
Mailing Address - Phone:830-315-6400
Mailing Address - Fax:
Practice Address - Street 1:327 EARL GARRETT ST STE 108
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-4500
Practice Address - Country:US
Practice Address - Phone:830-315-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19829235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid