Provider Demographics
NPI:1982930780
Name:BRYANT, STACIE L (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:L
Last Name:BRYANT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MISS
Other - First Name:STACIE
Other - Middle Name:L
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:603 PORT DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-1239
Mailing Address - Country:US
Mailing Address - Phone:317-272-8238
Mailing Address - Fax:
Practice Address - Street 1:603 PORT DRIVE
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-4612
Practice Address - Country:US
Practice Address - Phone:317-272-8238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-29
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003399A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist