Basic Information
| Provider Information | |||||||||
| NPI: | 1932326659 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUTTERMAN | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 928 DIAMOND SPRINGS RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234556601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573951975 | ||||||||
| FaxNumber: | 7574257180 | ||||||||
| Practice Location | |||||||||
| Address1: | 4560 SOUTH BLVD | ||||||||
| Address2: | 310 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234521160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574903223 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2202003346 | VA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 004979907 | 05 | VA | MEDICAID |