Provider Demographics
NPI:1336263227
Name:STACIA, EDWIN ALFRED JR
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:ALFRED
Last Name:STACIA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 RIDGEMONT HILL RD
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-8119
Mailing Address - Country:US
Mailing Address - Phone:832-549-2924
Mailing Address - Fax:
Practice Address - Street 1:2421 RIDGEMONT HILL RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-8119
Practice Address - Country:US
Practice Address - Phone:832-549-2924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8729235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist