Provider Demographics
NPI:1447672381
Name:GOSSMAN, STACY (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:GOSSMAN
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 1:100 REDSTONE CT
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43023-8037
Mailing Address - Country:US
Mailing Address - Phone:614-638-4197
Mailing Address - Fax:
Practice Address - Street 1:100 REDSTONE CT
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:OH
Practice Address - Zip Code:43023-8037
Practice Address - Country:US
Practice Address - Phone:614-638-4197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-6058235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist