Provider Demographics
NPI:1972977197
Name:MAIJALA, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MAIJALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 94
Mailing Address - Street 2:
Mailing Address - City:PAINESDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49955-0094
Mailing Address - Country:US
Mailing Address - Phone:906-370-2142
Mailing Address - Fax:
Practice Address - Street 1:1400 POPLAR ST
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1121
Practice Address - Country:US
Practice Address - Phone:906-482-6644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-26
Last Update Date:2015-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101004992235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist