Provider Demographics
NPI:1558941492
Name:STURDIVANT, KACEY LAUREN (SLP)
Entity type:Individual
Prefix:
First Name:KACEY
Middle Name:LAUREN
Last Name:STURDIVANT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-0749
Mailing Address - Country:US
Mailing Address - Phone:704-869-2088
Mailing Address - Fax:980-288-4239
Practice Address - Street 1:131 W INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-4338
Practice Address - Country:US
Practice Address - Phone:980-305-8780
Practice Address - Fax:980-892-0404
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2024-07-15
Deactivation Date:2024-05-05
Deactivation Code:
Reactivation Date:2024-07-12
Provider Licenses
StateLicense IDTaxonomies
NC30002818235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist