Provider Demographics
NPI:1295971612
Name:BUSBOOM, STACEY ANN (EDS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:ANN
Last Name:BUSBOOM
Suffix:
Gender:F
Credentials:EDS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4535 CHANDLER CT
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30656-3688
Mailing Address - Country:US
Mailing Address - Phone:770-625-0029
Mailing Address - Fax:
Practice Address - Street 1:4535 CHANDLER CT
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30656-3688
Practice Address - Country:US
Practice Address - Phone:770-625-0029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006818235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA432013779AMedicaid