Provider Demographics
NPI:1447460787
Name:LONG, STACY ELIZABETH (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:ELIZABETH
Last Name:LONG
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 1:4560 SE INTERNATIONAL WAY
Mailing Address - Street 2:STE 100
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:971-206-5200
Mailing Address - Fax:971-206-5203
Practice Address - Street 1:1900 ATRIUM PARKWAY
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559
Practice Address - Country:US
Practice Address - Phone:971-206-5200
Practice Address - Fax:971-206-5203
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101002235Z00000X
CA13820235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist