Provider Demographics
NPI:1770140162
Name:CHASTAIN, STACIE MARIE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:MARIE
Last Name:CHASTAIN
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:PO BOX 2060
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-2060
Mailing Address - Country:US
Mailing Address - Phone:916-989-3509
Mailing Address - Fax:
Practice Address - Street 1:6960 DESTINY DR STE 112
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2995
Practice Address - Country:US
Practice Address - Phone:916-947-1812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24793235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist