Basic Information
| Provider Information | |||||||||
| NPI: | 1245383983 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COOPER LUCIDO | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | M.ED. CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13 SUNSET DR | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019152319 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 CUMMINGS CTR | ||||||||
| Address2: | SUITE 3850 | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019156142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782320332 | ||||||||
| FaxNumber: | 9782321103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 4438 | MA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 0709379 | 05 | MA | MEDICAID | SP0184 | 01 | MA | BLUE CROSS | OTHER |