Provider Demographics
NPI:1801673819
Name:PRUETT, STACY R (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:R
Last Name:PRUETT
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 1:75 SADDLERS RUN
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-2457
Mailing Address - Country:US
Mailing Address - Phone:386-222-3345
Mailing Address - Fax:
Practice Address - Street 1:75 SADDLERS RUN
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-2457
Practice Address - Country:US
Practice Address - Phone:386-222-3345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18136235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist