Provider Demographics
NPI:1477947596
Name:WHITE, STACY (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:WHITE
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 1:1000 SAINT LOUIS AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3366
Mailing Address - Country:US
Mailing Address - Phone:817-921-5020
Mailing Address - Fax:817-921-5022
Practice Address - Street 1:3145 DENTON HWY
Practice Address - Street 2:
Practice Address - City:HALTOM CITY
Practice Address - State:TX
Practice Address - Zip Code:76117-3710
Practice Address - Country:US
Practice Address - Phone:817-831-1078
Practice Address - Fax:817-921-5022
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19415235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist