Provider Demographics
NPI:1700084142
Name:LIM, STACEY ROCHELLE (AUD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:ROCHELLE
Last Name:LIM
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 HEALTH PROFESSIONS BLDG
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48859-0001
Mailing Address - Country:US
Mailing Address - Phone:989-774-3904
Mailing Address - Fax:989-774-1891
Practice Address - Street 1:1101 HEALTH PROFESSIONS BLDG
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48859-0001
Practice Address - Country:US
Practice Address - Phone:989-774-3904
Practice Address - Fax:989-774-1891
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000660231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1700084142OtherNPI
MI1601000660OtherSTATE LICENSE
MI170008414OtherNPI