Basic Information
Provider Information
NPI: 1003000456
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HOBAN
FirstName: STACIE
MiddleName: ANN
NamePrefix: MS.
NameSuffix:  
Credential: MS, CCC-SLP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 300 OCEAN AVE
Address2: SPEECH AND LANGUAGE
City: REVERE
State: MA
PostalCode: 021513675
CountryCode: US
TelephoneNumber: 7814856131
FaxNumber:  
Practice Location
Address1: 300 OCEAN AVE
Address2: SPEECH AND LANGUAGE
City: REVERE
State: MA
PostalCode: 021513675
CountryCode: US
TelephoneNumber: 7814856131
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/29/2007
LastUpdateDate: 08/29/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
235Z00000X6638MAY Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 

No ID Information.


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