Provider Demographics
NPI:1447445259
Name:PROVOSTY, STACIE MARIE (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:MARIE
Last Name:PROVOSTY
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 1:2833 JOSEPH ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-7043
Mailing Address - Country:US
Mailing Address - Phone:504-864-8311
Mailing Address - Fax:504-864-8311
Practice Address - Street 1:3419 SAINT CLAUDE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70117-6144
Practice Address - Country:US
Practice Address - Phone:504-330-8160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5819235Z00000X
OH8000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist