Provider Demographics
NPI:1841360690
Name:KILLEEN, STACEY LYNN (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:LYNN
Last Name:KILLEEN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
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Mailing Address - Street 1:219 PRIMROSE DR
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-4632
Mailing Address - Country:US
Mailing Address - Phone:219-742-1400
Mailing Address - Fax:
Practice Address - Street 1:219 PRIMROSE DR
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-4632
Practice Address - Country:US
Practice Address - Phone:219-742-1400
Practice Address - Fax:219-809-2674
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.006920235Z00000X
IN22005278A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist