Provider Demographics
NPI:1528496320
Name:CROWDER, STACEY L (MED, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:L
Last Name:CROWDER
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:MISS
Other - First Name:STACEY
Other - Middle Name:LE-ANN
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, CCC-SLP
Mailing Address - Street 1:335 FOUR MILE RD
Mailing Address - Street 2:PO BOX 260005
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-4506
Mailing Address - Country:US
Mailing Address - Phone:843-488-6700
Mailing Address - Fax:
Practice Address - Street 1:335 FOUR MILE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4506
Practice Address - Country:US
Practice Address - Phone:843-488-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-15
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4191235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist