Provider Demographics
NPI:1881258473
Name:MANNING, STACEY ROSCHEL
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ROSCHEL
Last Name:MANNING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 PRIVATE ROAD 13261
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-1229
Mailing Address - Country:US
Mailing Address - Phone:870-299-3686
Mailing Address - Fax:
Practice Address - Street 1:131 PRIVATE ROAD 13261
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-1229
Practice Address - Country:US
Practice Address - Phone:870-299-3686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36823235Z00000X
TX87670101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty