Provider Demographics
NPI:1881917193
Name:STACY, SCOTT ANTHONY (SLP)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:ANTHONY
Last Name:STACY
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 CRUTCHFIELD ST
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-4408
Mailing Address - Country:US
Mailing Address - Phone:615-278-0308
Mailing Address - Fax:
Practice Address - Street 1:1101 GLEN OAKS RD.
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-2529
Practice Address - Country:US
Practice Address - Phone:931-684-8340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP0000001736235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist