Provider Demographics
NPI:1356881593
Name:STAHL, ADRIAN M (SLP-CCCS)
Entity type:Individual
Prefix:MRS
First Name:ADRIAN
Middle Name:M
Last Name:STAHL
Suffix:
Gender:F
Credentials:SLP-CCCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 AIRWAYS PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5885
Mailing Address - Country:US
Mailing Address - Phone:662-349-8787
Mailing Address - Fax:662-349-8757
Practice Address - Street 1:12311 ASHLEY DR STE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2950
Practice Address - Country:US
Practice Address - Phone:228-357-5253
Practice Address - Fax:662-349-8757
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS4283235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist