Provider Demographics
NPI:1811164890
Name:STACKHOUSE, KARLENE MARIE (MA CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:KARLENE
Middle Name:MARIE
Last Name:STACKHOUSE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:KARLENE
Other - Middle Name:MARIE
Other - Last Name:ANDREWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:9 MILLARD ST
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:NY
Mailing Address - Zip Code:14837-1008
Mailing Address - Country:US
Mailing Address - Phone:607-377-7216
Mailing Address - Fax:
Practice Address - Street 1:9 MILLARD ST
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:NY
Practice Address - Zip Code:14837-1008
Practice Address - Country:US
Practice Address - Phone:607-377-7216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4126235Z00000X
NY018603235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1811164890Medicaid