Provider Demographics
NPI:1144510413
Name:STACY PAYNE SPEECH PATHOLOGY, INC
Entity type:Organization
Organization Name:STACY PAYNE SPEECH PATHOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:310-562-0187
Mailing Address - Street 1:11965 VENICE BLVD STE 404
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3978
Mailing Address - Country:US
Mailing Address - Phone:310-562-0187
Mailing Address - Fax:310-566-7697
Practice Address - Street 1:11965 VENICE BLVD STE 404
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3978
Practice Address - Country:US
Practice Address - Phone:310-562-0187
Practice Address - Fax:310-566-7697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP9299261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech