Provider Demographics
NPI:1205488053
Name:VISAGE, STACY (MS-CCC, SLP)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:VISAGE
Suffix:
Gender:F
Credentials:MS-CCC, SLP
Other - Prefix:MRS
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:VISAGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS-CCC, SSLP
Mailing Address - Street 1:4367 S 2675 W
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-1919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4401 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3195
Practice Address - Country:US
Practice Address - Phone:801-387-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8271884-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist