MEDICARE: MS. STACI SUNESON 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	DOH-LL00002897	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1899SC	OTHER		BL CROSS BL SHIELD

General Provider Information

NPI Number	:	1396764957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STACI SUNESON CCC-SLP

Provider Business Mailing Address
First Line	:	108 22ND AVE SW
Second Line	:	SUITE 14
City	:	OLYMPIA
State	:	WA
Zip	:	98501-2871
Country	:	US
Telephone Number	:	360-943-1180
Fax Number	:	360-943-3494

Provider Business Practice Location Address
First Line	:	108 22ND AVE SW
Second Line	:	SUITE 14
City	:	OLYMPIA
State	:	WA
Zip	:	98501-2871
Country	:	US
Telephone Number	:	360-943-1180
Fax Number	:	360-943-3494

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

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	07/08/2015

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Directions to “ MS. STACI SUNESON CCC-SLP” Practice Location

Language	Start Address	Practice Location

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