Provider Demographics
NPI:1962768077
Name:CLAY, STACIE MAREE (MA,CCC-SLP)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:MAREE
Last Name:CLAY
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 1:5148 INDIANOLA AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1229
Mailing Address - Country:US
Mailing Address - Phone:317-366-5084
Mailing Address - Fax:
Practice Address - Street 1:6701 SOUTH ANTHONY BLVD.
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46816-2035
Practice Address - Country:US
Practice Address - Phone:260-447-1591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004452A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist