MEDICARE: STACEY WALLEN PH. D., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SA5662	FL
2	235Z00000X	Speech-Language Pathologist	SLP006932	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	SLP006932	OTHER	GA	GA LICENSE NUMBER
2	SA5662	OTHER	FL	STATE LICENSE NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376657114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY WALLEN PH. D., CCC-SLP

Provider Business Mailing Address
First Line	:	2209 DISCOVERY CIR W
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33442-1006
Country	:	US
Telephone Number	:	954-415-4069
Fax Number	:	954-596-0355

Provider Business Practice Location Address
First Line	:	3201 ROCKPORT DR
Second Line	:
City	:	LITHONIA
State	:	GA
Zip	:	30038-1834
Country	:	US
Telephone Number	:	954-415-4069
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	04/08/2014

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Directions to “ STACEY WALLEN PH. D., CCC-SLP” Practice Location

Language	Start Address	Practice Location

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