Basic Information
| Provider Information | |||||||||
| NPI: | 1467492181 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREIRA | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOETSCH | ||||||||
| OtherFirstName: | STACI | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 530 SOUTH C ST. UNIT B | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147342330 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1301 W PROVIDENCE AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146394990 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 11326 | CA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.