1356881593 NPI number — MRS. ADRIAN M STAHL SLP-CCCS

Table of content: MRS. ADRIAN M STAHL SLP-CCCS (NPI 1356881593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356881593 NPI number — MRS. ADRIAN M STAHL SLP-CCCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STAHL
Provider First Name:
ADRIAN
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
SLP-CCCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356881593
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
83 AIRWAYS PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38671-5885
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-349-8787
Provider Business Mailing Address Fax Number:
662-349-8757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12311 ASHLEY DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39503-2950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-357-5253
Provider Business Practice Location Address Fax Number:
662-349-8757
Provider Enumeration Date:
03/07/2017

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:  S4283 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 111415500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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