Provider Demographics
NPI:1356404552
Name:CARROLL, STACEY ANN (MA CCC SLP)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:ANN
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:ANN
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC/SLP/L
Mailing Address - Street 1:10550 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-2522
Mailing Address - Country:US
Mailing Address - Phone:773-742-9817
Mailing Address - Fax:312-506-5333
Practice Address - Street 1:10550 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-2522
Practice Address - Country:US
Practice Address - Phone:773-742-9817
Practice Address - Fax:312-506-5333
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2013-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008234235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist