Provider Demographics
NPI:1376984757
Name:MELLEN, STACIE RENEE' (SLP-A)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:RENEE'
Last Name:MELLEN
Suffix:
Gender:F
Credentials:SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8245 N 27TH AVE APT 1035
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-6362
Mailing Address - Country:US
Mailing Address - Phone:602-697-6014
Mailing Address - Fax:
Practice Address - Street 1:8245 N 27TH AVE APT 1035
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-6362
Practice Address - Country:US
Practice Address - Phone:602-697-6014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA84032355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant