Healthcare Provider Details

I. General information

NPI: 1821396094
Provider Name (Legal Business Name): STACIA L. THOMAS AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACIA BARBOZA

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 FOREST AVE STE 301
PORTLAND ME
04103-1889
US

IV. Provider business mailing address

190 RIVERSIDE ST SUITE 6B
PORTLAND ME
04103-1073
US

V. Phone/Fax

Practice location:
  • Phone: 207-797-5753
  • Fax:
Mailing address:
  • Phone: 207-661-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAP2351
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: