Provider Demographics
NPI:1134374580
Name:BASTIEN-RENELIQUE, STACY (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:BASTIEN-RENELIQUE
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2066 PEARSON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4727
Mailing Address - Country:US
Mailing Address - Phone:347-885-5601
Mailing Address - Fax:
Practice Address - Street 1:111 LIVINGSTON ST
Practice Address - Street 2:SUITE 1101
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-1260
Practice Address - Country:US
Practice Address - Phone:718-625-4055
Practice Address - Fax:718-625-4702
Is Sole Proprietor?:No
Enumeration Date:2008-11-27
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist