Provider Demographics
NPI:1700074325
Name:PAUL, STACY (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:PAUL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 GENEVIEVE DR
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-9543
Mailing Address - Country:US
Mailing Address - Phone:717-979-2812
Mailing Address - Fax:
Practice Address - Street 1:701 GENEVIEVE DR
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055-9543
Practice Address - Country:US
Practice Address - Phone:717-979-2812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL007090235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019311720004OtherDEPT OF PUBLIC WELFARE