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Individual
STACEY WALLEN
Active
Individual
STACEY WALLEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PH. D., CCC-SLP
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
SA5662
FL
235Z00000X
Speech-Language Pathologist
Primary
SLP006932
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003121866B
—
GA
05
—
8857075
—
FL
01
—
SA5662
STATE LICENSE NUMBER
FL
01
—
SLP006932
GA LICENSE NUMBER
GA
Enumeration date
08/18/2006
Last updated
04/08/2014
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