MEDICARE: STACEY NICOLE BASTIN 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	11971	NC

General Provider Information

NPI Number	:	1487521001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY NICOLE BASTIN SLP

Provider Business Mailing Address
First Line	:	4210 HUFF RD
Second Line	:
City	:	ARCHDALE
State	:	NC
Zip	:	27263-9449
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4144 MENDENHALL OAKS PKWY STE 103
Second Line	:
City	:	HIGH POINT
State	:	NC
Zip	:	27265-8414
Country	:	US
Telephone Number	:	336-601-8604
Fax Number	:	336-899-7111

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

Provider Enumeration Date	:	10/20/2025
Last Update Date	:	10/20/2025

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Directions to “ STACEY NICOLE BASTIN SLP” Practice Location

Language	Start Address	Practice Location

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