Provider Demographics
NPI:1700927969
Name:STACY, LAURENCE WILLIAM (MA CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:LAURENCE
Middle Name:WILLIAM
Last Name:STACY
Suffix:
Gender:M
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 3RD ST SE
Mailing Address - Street 2:
Mailing Address - City:STEWARTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55976-1314
Mailing Address - Country:US
Mailing Address - Phone:507-533-4618
Mailing Address - Fax:
Practice Address - Street 1:2746 SUPERIOR DR NW
Practice Address - Street 2:SUITE 300
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-8343
Practice Address - Country:US
Practice Address - Phone:507-288-0064
Practice Address - Fax:507-288-3993
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5186235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist