Provider Demographics
NPI:1053761437
Name:STANLEY, RAEGAN MAE (SLP)
Entity type:Individual
Prefix:
First Name:RAEGAN
Middle Name:MAE
Last Name:STANLEY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:RAEGAN
Other - Middle Name:M
Other - Last Name:GUELICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:650 N SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6677
Mailing Address - Country:US
Mailing Address - Phone:907-376-6363
Mailing Address - Fax:907-376-6366
Practice Address - Street 1:900 COMMONWEALTH PL STE 200
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4530
Practice Address - Country:US
Practice Address - Phone:570-317-1997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34243235Z00000X
PASL012895235Z00000X
MD10975237600000X
VA2202009502235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter