Provider Demographics
NPI:1881167104
Name:BRAND, STACY L
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:BRAND
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 1:28520 WOOD CANYON DR APT 125
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-5272
Mailing Address - Country:US
Mailing Address - Phone:949-939-3446
Mailing Address - Fax:
Practice Address - Street 1:26284 OSO RD STE 114
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1629
Practice Address - Country:US
Practice Address - Phone:949-824-9557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASPA39112355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANONEOtherNONE