Healthcare Provider Details

I. General information

NPI: 1639191216
Provider Name (Legal Business Name): STACEY LYNN SLAVKIN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LAHEY CLINIC 41 MALL ROAD
BURLINGTON MA
01805-0001
US

IV. Provider business mailing address

LAHEY CLINIC 41 MALL ROAD
BURLINGTON MA
01805-0001
US

V. Phone/Fax

Practice location:
  • Phone: 781-744-8869
  • Fax:
Mailing address:
  • Phone: 781-744-8869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6505
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: