Basic Information
| Provider Information | |||||||||
| NPI: | 1477947596 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | STACY | ||||||||
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| Credential: | M.S. CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 SAINT LOUIS AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | FT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179215020 | ||||||||
| FaxNumber: | 8179215022 | ||||||||
| Practice Location | |||||||||
| Address1: | 3145 DENTON HWY | ||||||||
| Address2: | |||||||||
| City: | HALTOM CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761173710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178311078 | ||||||||
| FaxNumber: | 8179215022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2015 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 19415 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.