Provider Demographics
NPI:1548549801
Name:WILSON, STACEY ELIZABETH (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:ELIZABETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TUSCUMBIA
Mailing Address - State:AL
Mailing Address - Zip Code:35674-2803
Mailing Address - Country:US
Mailing Address - Phone:256-740-2995
Mailing Address - Fax:
Practice Address - Street 1:507 N HOOK ST
Practice Address - Street 2:
Practice Address - City:TUSCUMBIA
Practice Address - State:AL
Practice Address - Zip Code:35674-1867
Practice Address - Country:US
Practice Address - Phone:256-381-4310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2420235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist