Provider Demographics
NPI:1639684087
Name:CHILDERS, STACEY (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:CHILDERS
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 1:11606 FICUS ST
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-2618
Mailing Address - Country:US
Mailing Address - Phone:913-634-3221
Mailing Address - Fax:
Practice Address - Street 1:4200 PURDY LN
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-1469
Practice Address - Country:US
Practice Address - Phone:561-804-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15876235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist