Provider Demographics
NPI:1265753966
Name:HEADRICK, STACEY (MEDCCC-SLP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HEADRICK
Suffix:
Gender:F
Credentials:MEDCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 PADDINGTON AVE NE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-8201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5725 OLEANDER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4745
Practice Address - Country:US
Practice Address - Phone:910-313-2111
Practice Address - Fax:910-313-2119
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8363235Z00000X
VA2202004182235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist