Provider Demographics
NPI:1104077965
Name:THOMSEN, STACY RAE (MA,CCC/SLP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:RAE
Last Name:THOMSEN
Suffix:
Gender:F
Credentials:MA,CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40460 254TH ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-5415
Mailing Address - Country:US
Mailing Address - Phone:605-996-2899
Mailing Address - Fax:605-996-0721
Practice Address - Street 1:40460 254TH ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-5415
Practice Address - Country:US
Practice Address - Phone:605-996-2899
Practice Address - Fax:605-996-0721
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist