Healthcare Provider Details

I. General information

NPI: 1073135885
Provider Name (Legal Business Name): STACEY EDGAR SLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 RESERVOIR AVE
MANCHESTER NH
03104-4468
US

IV. Provider business mailing address

20 HECKER ST
MANCHESTER NH
03102-3975
US

V. Phone/Fax

Practice location:
  • Phone: 603-624-6352
  • Fax:
Mailing address:
  • Phone: 603-624-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235500000X
TaxonomySpeech/Language/Hearing Specialist/Technologist
License Number71891
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: