Healthcare Provider Details

I. General information

NPI: 1982930780
Provider Name (Legal Business Name): STACIE L. BRYANT M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS STACIE L. BRYANT

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 PORT DRIVE
AVON IN
46123-4612
US

IV. Provider business mailing address

603 PORT DR
AVON IN
46123-1239
US

V. Phone/Fax

Practice location:
  • Phone: 317-272-8238
  • Fax:
Mailing address:
  • Phone: 317-272-8238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22003399A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: