Provider Demographics
NPI:1396469680
Name:MOULTON, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MOULTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MANNING RD
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:VT
Mailing Address - Zip Code:05655-9431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 MANNING RD
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:VT
Practice Address - Zip Code:05655-9431
Practice Address - Country:US
Practice Address - Phone:802-279-3359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT144.0114464235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist