Provider Demographics
NPI:1518220805
Name:BENNETT, STACIE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 HEATHER LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07403-1507
Mailing Address - Country:US
Mailing Address - Phone:570-573-9103
Mailing Address - Fax:570-573-9103
Practice Address - Street 1:401 RIDGE RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:NJ
Practice Address - Zip Code:08810-3300
Practice Address - Country:US
Practice Address - Phone:732-230-3076
Practice Address - Fax:866-862-4631
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00655500235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist