1356404552 NPI number — MRS. STACEY ANN CARROLL MA CCC SLP

Table of content: MRS. STACEY ANN CARROLL MA CCC SLP (NPI 1356404552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356404552 NPI number — MRS. STACEY ANN CARROLL MA CCC SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARROLL
Provider First Name:
STACEY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA CCC SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HANSEN
Provider Other First Name:
STACEY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A.., CCC/SLP/L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356404552
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10550 RIDGEWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALOS PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60464-2522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-742-9817
Provider Business Mailing Address Fax Number:
312-506-5333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10550 RIDGEWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALOS PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60464-2522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-742-9817
Provider Business Practice Location Address Fax Number:
312-506-5333
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  146008234 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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