Provider Demographics
NPI:1679690010
Name:RICHARDSON, STACEY (MS, SLP-CCC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MS, SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70438-1007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 8TH AVE
Practice Address - Street 2:
Practice Address - City:FRANKLINTON
Practice Address - State:LA
Practice Address - Zip Code:70438-1007
Practice Address - Country:US
Practice Address - Phone:985-839-6508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1621625Medicaid