Provider Demographics
NPI:1093337230
Name:HARRIS, STACEY KELEEN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:KELEEN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2963 NW FILLMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-5165
Mailing Address - Country:US
Mailing Address - Phone:406-304-8330
Mailing Address - Fax:
Practice Address - Street 1:33461 SE PEORIA RD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-2521
Practice Address - Country:US
Practice Address - Phone:541-704-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-LIC-9724235Z00000X
MTMT-SLP-SP-LIC-9724235Z00000X
OR17834235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist