Provider Demographics
NPI:1275092900
Name:FINCANNON, LETITIA GAYLE (SPEECH PATHOLOGIST)
Entity Type:Individual
Prefix:
First Name:LETITIA
Middle Name:GAYLE
Last Name:FINCANNON
Suffix:
Gender:F
Credentials:SPEECH PATHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 E MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-1342
Mailing Address - Country:US
Mailing Address - Phone:512-900-7934
Mailing Address - Fax:
Practice Address - Street 1:2100 E MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-1342
Practice Address - Country:US
Practice Address - Phone:512-900-7934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12423235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist